Nashville Surgical Instruments


The Kumar PRE-VIEW* Cholangiography

Frequently Asked Questions

1. Is there leakage of bile around the needle during injection of dye?

 

Since no incision (such as a ductotomy) has been made and biliary access has been obtained by only a needle puncture, there is no leakage of dye around the needle unless there is Cystic Duct Obstruction. See number 5 below.

 

2. Is there leakage of bile from the needle hole after the needle is removed?

 

Since the gallbladder has been emptied by aspiration after cholangiography, bile leakage is only a small droplet, just as upon cystic ductotomy.

 

3. Can the needle go through the back wall of the Hartmann’s pouch?

 

No. The needle length is only 1.25 cm and the angle of entry of the needle does not point towards the back wall of the Hartmann’s pouch.

 

4. If a stone is located in the Hartmann’s pouch, can it be pushed by the needle or washed by the dye in to the common bile duct? The Washable Stone?

 

This problem has not occurred in clinical practice in tens of thousands of cholangiograms that have been performed with this method.

 

Three factors prevent the passage of a stone into the common bile duct during injection of dye into the Hartmann’s Pouch:

1. The valves of Heister in the cystic duct.

2. The cystic duct is tortuous and not a straight, rigid conduit.

3. The radiographic dye is slick and easily flows around the stones.

 

 In addition, we know that a tiny stone in the cystic duct can be pushed in to the common bile duct during conventional cystic duct cannulation also. Experience has shown that these are not of clinical significance and pass uneventfully.

 

5. How can this method work if there is cystic duct obstruction?

 

Cystic duct obstruction can occur with or without Hydrops:

 

a. In the absence of Hydrops, the stone is small and may even consist of biliary sludge or a mucous plug. The cystic duct is not completely obstructed since a complete obstruction leads to Hydrops. The maneuvers of cystic duct dissection and milking of the cystic duct towards the gallbladder will dislodge the small stone, sludge or mucous and achieve cystic duct patency allowing the flow of dye for cholangiography.

 

b. When there is Hydrops, the cystic duct is completely obstructed by a stone that is impacted at the neck of the gallbladder. This obstruction does not allow the gallbladder to empty and the secretions collect within the gallbladder. The gallbladder becomes so large & distended that it cannot even be grasped. This is also called a Hot Gallbladder.

 

i)      In our method this gallbladder is pushed upwards with a grasper through the right lateral port. The jaws of the grasper are kept open since the gallbladder cannot be grasped.

ii)    The Kumar Clamp is then applied through the right mid-subcostal port. The jaws of the Kumar Clamp are also kept open for the same reason. The Kumar Clamp is placed as low as possible on the body of the gallbladder.

iii)  A fan-shaped retractor may be used to achieve additional exposure of the lower part of the body of the gallbladder..

iv)  The Catheter is then advanced & the gallbladder is punctured and aspirated first.

This relieves the pressure that was pushing the stone in to the neck of the gallbladder. Actually, a negative pressure has been created behind the stone.

 

v)    The stone can then be manipulated with a grasper through the midline port and is easily dislodged.

vi)  The decompressed gallbladder can then be grasped and dye for cholangiography can be injected, preferably through the same access that was used for aspiration.


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