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The right duct is freed up a short distance and a blood vessel loop passed around it for traction (Figure 6). If the tumor has involved the wall of either major duct with probable extension into the liver, the need for added lobectomy must be seriously considered. Occasionally, a third large duct, or even more, may be found on the right side, which must be conserved for implantation. Traction sutures are placed in the major ducts at the point of division for each duct (Figure 7).

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The two ducts of the specimen should be marked with different colored sutures for specific identification by the pathologist of possible infiltration of tumor at the point of division. Should this be found on frozen section study, more duct must be resected.

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The Silastic transhepatic biliary stents are positioned using a Coudé catheter as a preceding dilator that is drawn up the ducts and through the liver by the ring catheters. First, the ring catheters with the guide wires inside are brought out the open left and right hepatic ducts. Each curled (ring) end is cut off and the remaining straight ring catheter is placed into the cut leading end of a No. 16 French Coudé catheter. Each ring catheter is then secured with a mattress suture through itself and the Coudé. Both catheters are pulled up into the ducts (Figure 8) using traction on the ring catheter at the surface of the liver. The Coudé catheters may need to be manipulated back and forth so as to dilate the ductal systems.

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A No. 14 French Silastic transhepatic biliary stent is positioned in the open end of the No. 16 Coudé French catheter and anchored with mattress sutures of silk which are passed through the wall of the Coudé catheter. With traction on the Coudé catheters the Silastic stents with multiple holes are drawn into the liver in a position with no holes beyond the exit of the plastic tubes (Figure 9). Thus, there are holes present within the liver and the portion that projects into the Roux-en-Y of the jejunum. Short horizontal mattress sutures of absorbable material are placed around the stents on the surface of the liver at their point of exit. The liver is compressed without disruption about each catheter.

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