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Step 3: Confirmation by Cholangiography:
This Cholangiography has to be other than the usual Cystic Duct Cholangiography. Because, if the Common Bile Duct has been mis-identified as the Cystic Duct and Cystic Duct Cholangiography is attempted, the injury of the “mistaken ductotomy,” of the Common Bile Duct, will result.

Kumar Cholangiography* is Better:
(Figure 2)

  1. The Kumar Clamp® is a 5mm grasper. It is applied thru the right mid-subcostal port (in the conventional method) and is used as a grasper for traction at the infundibulum during dissection of the Cystic Duct.
  2. Cystic Duct is then milked towards the gallbladder to eliminate stones / sludge.
  3. The Kumar Clamp® has long atraumatic jaws. It is re-applied completely across the lower part of the body of the gallbladder. (Figure 2)
  4. The Kumar Catheter® is then advanced thru the Clamp channel. It carries a short 19 ga needle to puncture the Hartmann’s pouch of the gallbladder for biliary access, and dye injection.



There is No Cystic Duct Cannulation.

The injury of the Mistaken Ductotomy of the Common Bile Duct is thus eliminated.

The Cholangiogram in Figure 3 shows clips (arrow) on the fibro-aereolar tissue or Cystic Artery, lying adjacent to the planned site of clipping and cutting of the Cystic Duct. The Cystic Duct and the planned site of clipping have thus been confirmed.

The Cholangiogram in Figure 4 shows an impending transection of the Common Bile Duct. Clips (arrow) are located on a mis-identified Common Bile Duct.


Cystic Duct marking and Kumar Cholangiography* prevented a Common Duct Injury in this patient.

Prevent CBD Injury

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​The Aspiration Advantage

After cholangiography has been completed, please note that we have a 19 gauge needle of the Kumar Catheter® located in a dependent portion of the gallbladder. The Kumar Clamp® jaws are opened and the gallbladder is easily aspirated. This will make it easier to remove the gallbladder from the liver bed and to extract from the portsite.


Versatility
The Kumar Clamp® functions as a Grasper, a Cholangiography instrument and an Aspirator.

                                               Fig 3 & 4

Fig 2

Fig 1: The Kumar Clamp® and Catheter.

Prevention of Common Bile Duct Injury
by Cystic Duct Marking


The concept is to mark the site of clipping of The Cystic Duct with radio-opaque clips and confirm this fact by Cholangiography.

Step 1: The (assumed) Cystic Duct is identified and dissected.
Step 2: It is marked by placement of radio-opaque Clips upon

a. The fibro-aereolar tissue around the Cystic Duct
OR
b. Upon the Cystic Artery (Figure 1)