Procedure (cont.)

6. After the connection is made, the clamps are removed from both tubes. Gentle aspiration of the syringe will reveal whether or not there is an air bubble present at the connection. If so, the tubes must be reclamped, the connection separated, and the bubbles expelled before reconnecting. This procedure is repeated until no air bubbles can be identified at the connection of the t-tube to the extension tubing. (Air bubbles in the bile ducts look exactly like retained stones.)



7. The patient is rotated into a steep LPO (nearly left lateral) position and the fluoroscopic table is tilted about 30° head down. In this position, the left lobe of the liver is dependent, and the left intrahepatic ducts will fill by gravity. Also, in this position, the confluence of the right and left hepatic ducts is optimally demonstrated without overlap.



8. The water-soluble contrast agent is slowly injected by hand while duct filling is monitored by fluoroscopy. When the branching ducts in the left lobe of the liver have filled and the right hepatic ducts begin to fill, take the first spot image(s) (2-on-1 format, 109 kVp).

9. Roll the patient to the supine position and continue filling the ducts until the branches in the right lobe are filled along with the extrahepatic duct. Again, take a spot image(s) (2-on-1 format, 109 kVp). Try to time the exposure for when contrast squirts from the common bile duct (CBD) into the duodenum.