Malignant diseases of obstructive jaundice include cholangiocarcinoma, Klastin tumour, carcinomas of the: pancreatic head, duodenum, Ampulla of Vater, gallbladder and lymph nodes at the porta. Benign diseases are biliary stricture, choledochal cyst, stenosis of the papilla, Mirizzi’s syndrome and extra-hepatic biliary atresia.

CBD exploration: After the exploration of the common bile duct (CBD), cholecystectomy is accomplished. Routine cystic duct cholangiography is conducted along with pre-exploratory size of the stones and their location.

Biliary calculus disease:

• Therapeutic endoscopy: Endoscopic sphincterotomy is done for retained stones after cholecystectomy. ERC or endoscopic retrograde cholangiography is done after a cholangiogram shows the size, location and number of the stones. The procedure also involves cannulation of the ampulla. The extraction is done with balloon dilation and basket extraction.
• Laparoscopic cholecystectomy: This is carried out along with trans-cystic CBD exploration. The cystic duct is dilated following a cholecystectomy and the stones are extracted with baskets.

Extra-hepatic biliary atresia: There are three different types – atresia of the CBD, common hepatic duct and right and left ducts. A pre-operative percutaneous liver biopsy is done and a resection of the biliary tract is done thereafter. A Roux-en-Y loop is conducted as reconstructive surgery.

Ampullary tumours: Small tumours <2 cm are excised locally. These usually arise from the Ampulla of Vater or biliary duct. Follow-up endoscopy is essential in about 6 months, post-operatively.

Choledocholithiasis surgery: Several midline incisions are made. The peritoneum is opened and adhesions are divided. First, the liver is retracted upwards. Then. the colon and duodenum are retracted downwards. The peritoneal fold is incised and a blunt dissection defines the CBD and the cystic duct. An intra-operative cholangiography is carried out and the cystic duct is ligated and cut.