Plate 103

### Details of Procedure

The surgeon is occasionally faced with the difficult problem of finding the strictured area or blind end of the hepatic duct. The adhesions between the duodenum and hilus of the liver are divided carefully by sharp and blunt dissection (Figure 1). Great care must be exercised to avoid unnecessary bleeding and possible injury to the underlying structures. Usually, it is easier to start the dissection quite far laterally and to free up the superior surface of the right lobe of the liver from the adherent duodenum, hepatic flexure of the colon, and omentum. Sharp dissection is used along the liver margins to avoid tearing the liver capsule, which results in a troublesome ooze. After the edge of the adhesion has been incised, blunt dissection will be more effective and safer in freeing up the undersurface of the liver. The exposure should be directed toward identifying and exposing the foramen of Winslow. The stomach may or may not have to be dissected away from the liver. Usually, the duodenum is drawn up into the old gallbladder bed and fixed by dense adhesions. The second portion of the duodenum is mobilized medially (Kocher maneuver), following division of the peritoneum along its lateral margin (Figure 2). As the duodenum is reflected downward and the undersur-face of the liver is retracted upward, the upper portion of the dilated duct may be verified by aspiration of bile through a fine hypodermic needle (Figure 3), and a cholangiogram may be performed. The needle may be left in place, and an incision is made alongside the needle until a free flow of bile is obtained. ...

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