A patient undergoing laparoscopic cholecystectomy has an intraoperative cholangiogram (IOC) that shows a filling defect in the CBD and no flow of dye into the duodenum. The NEXT most appropriate step is:

• A Complete the cholecystectomy and refer for post-operative ERCP within 72 hours
• B Abandon the laparoscopy and proceed to open common bile duct exploration immediately
• C Intraoperative laparoscopic common bile duct exploration (LCBDE) if surgical expertise is available, or complete cholecystectomy and proceed to early post-operative ERCP ✓
• D Irrigate the CBD with saline via the cystic duct and close, as the stone will likely pass spontaneously

Explanation

An intraoperative cholangiogram showing a CBD stone should be managed in one of two ways depending on available expertise: (1) laparoscopic common bile duct exploration (LCBDE) at the same sitting, which has equivalent stone clearance rates to ERCP and avoids a second procedure; or (2) if LCBDE expertise is unavailable, complete the cholecystectomy and arrange early (ideally within 24–72h) post-operative ERCP. Open CBD exploration has largely been superseded by laparoscopic or endoscopic approaches. Abandoning the procedure without clearing the stone or saline irrigation alone is suboptimal management.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.