This is a procedure favored by many in place of the transduodenal approach for stones impacted in the ampulla, and is indicated for the treatment of primary common bile duct stones with a dilated common bile duct, or benign strictures of the distal bile duct. The procedure should not be considered for a nondilated common duct, recurrent pancreatitis, sclerosing cholangitis, or common bile duct stone amenable to endoscopic removal. The procedure of choledochoduodenostomy in properly selected patients may be far safer, with long-term results more satisfactory, than those that follow more complicated procedures for the excision of diverticuli.
Liver function studies are evaluated, and consultation with an endoscopist should be considered. Antibiotics are given preoperatively.
General anesthesia is preferred. The anesthesiologist must consider liver function studies as well as age and general condition of the patient in selecting the type of anesthetic to be administered.
The patient is placed flat on the table with the feet lower than the head. Slight rotation toward the side of the surgeon may improve exposure.
The skin is prepared from the lower chest to the lower abdomen.
A right subcostal incision or an upper midline incision is made. Adhesions to the peritoneum are carefully freed up, including those that tend to prevent mobilization of the liver needed for exposure of the common duct.
Following a general abdominal exploration, special attention is given to the size of the common duct as well as any evidence of ulcer deformity or acute inflammatory involvement of the first portion of the duodenum. A biopsy of the liver may be considered and needle aspiration of bile from the common duct is obtained for culture to guide appropriate antibiotic therapy. The diameter of the duct is measured and should be 2 to 2½ cm in diameter. If the gallbladder has not been removed previously, it should be excised, particularly if stones are present. The cystic duct and the common duct are carefully palpated for possible calculi. Any calculus, especially in the lower end of the common duct, should be removed when the common duct is opened for the anastomosis. Any inflammatory involvement of the duodenum should be noted, as this may contraindicate the planned procedure.
The duodenum and head of the pancreas should be mobilized by incising the peritoneum from the region of the foramen of the Winslow around to the third portion of the duodenum (figure 1). The entire duodenum should be freed up by the Kocher maneuver and further mobilized by the hand placed under the head of the pancreas.