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After the field has been adequately walled off, the surgeon introduces the left index finger into the foramen of Winslow and, with finger and thumb, thoroughly palpates the region for evidence of calculi in the common duct as well as for thickening of the head of the pancreas. A half-length clamp, with the concavity turned upward, is used to grasp the undersurface of the gallbladder to attain traction toward the operator (Figure 9). The early application of clamps in the region of the ampulla of the gallbladder is one of the frequent causes of accidental injury to the common duct. This is especially true when the gallbladder is acutely distended, because the ampulla of the gallbladder may run parallel to the common duct for a considerable distance. If the clamp is applied blindly where the neck of the gallbladder passes into the cystic duct, part or all of the common duct may be accidentally included in it (Figure 10). For this reason it is always advisable to apply the half-length clamp well up on the undersurface of the gallbladder before any attempt is made to visualize the region of the ampulla of the gallbladder. The enucleation of the gallbladder is started by dividing the peritoneum on the inferior aspect of the gallbladder and extending it downward to the region of the ampulla. The peritoneum usually is divided with an electrocautery or long Metzenbaum dissecting scissors. The incision is carefully extended downward along with hepatoduodenal ligament (Figures 11 and 12). By means of blunt gauze dissection the region of the ampulla is freed down to the region of the cystic duct (Figure 13). After the ampulla of the gallbladder has been clearly defined, the clamp on the undersurface of the gallbladder is reapplied lower to the region of the ampulla.

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With traction maintained on the ampulla, the cystic duct is defined by means of blunt dissection (Figure 13). A long right-angle clamp is ...

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