The cystic duct incision done for performing IOC is used for transcystic CBDE (TCBDE). Care is taken to avoid a cystic duct incision too close to the CBD, in order to reduce the risk of instrumental CBD injury. The incision must also not be too far from the CBD, because the presence of obstructive cystic valves may preclude instrumental TCBDE. If the caliber of the sufficiently large CD is not dilated enough, it can be carefully dilated using a soft, flexible dilator, with care taken to avoid instrumental CBD injury.
Stone extraction through TCBDE can be performed using a three-wire soft Dormia basket with three different approaches:
■ By blunt introduction of the instrument into the CBD through the CD.
■ Under fluoroscopic guidance (safer for ensuring stone capture and avoiding instrumental CBD injury).
■ Under visual cholangioscopic guidance (for small stones).
A balloon catheter is not used during TCBDE, in order to avoid stone migration in the upper part of the CBD. In the case of huge, impacted, obstructive stones not amenable to extraction by using standard instrumental or endoscopic methods, the stone can be fragmented by using an endoluminal electrohydraulic or laser lithotripsy probe under endoscopic visual control.
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