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Sometimes it is impossible to dislodge a stone impacted in the ampulla of Vater by careful and repeated manipulation, and a more radical procedure is necessary. In such circumstances, the duodenum is mobilized by the Kocher maneuver, and the common duct is exposed throughout its course down to the duodenal wall. An incision is made in the lateral part of the peritoneal attachment of the duodenum, making it possible to mobilize the second portion of the duodenum (FIGURE 1). After the peritoneal attachment has been incised, blunt gauze dissection is used to sweep the duodenum medially. Occasionally, this will expose the retroduodenal portion of the common duct and will allow more direct palpation (FIGURE 2). A blunt metal probe is introduced downward to the point of the obstruction, and the location of the stone is more accurately determined by palpation. A scoop is passed down to the region of the ampulla of the common bile duct, and its course is directed carefully with the index finger and thumb of the surgeon’s left hand (FIGURE 3). With the tissues being held firmly by the thumb and index finger, it is usually possible to break up the impacted calculus with the scoop. Should this prove unsuccessful, it is necessary to open the anterior duodenal wall and expose the ampulla of the papilla (FIGURE 4).

Because opening the duodenum tends to increase the risk of complications, it should not be considered until all indirect methods have been tried. In fact, many surgeons proceed directly to choledochoduoenostomy (see Chapter 77), particularly in patients with a dilated common bile duct.

By exerting gentle pressure on a uterine sound or a biliary Fogarty catheter inserted into the common duct, the surgeon can determine the exact location of the papilla by palpation over the anterior wall of the duodenum. With the duodenal wall held taut in Babcock forceps or by silk sutures, an incision 3–4 cm long is made over this area, parallel to the long axis of the bowel. A transverse duodenotomy is also acceptable if the location of the ampulla has been identified adequately, and transverse closure of defect results in less narrowing and deformity of the duodenum. The field must be completely walled off by gauze sponges, and constant suction must be maintained to avoid contamination by bile and pancreatic juice. Small gauze sponges are then introduced upward and downward within the lumen of the duodenum to prevent further soiling. Long silk sutures are attached to each of these gauze sponges to ensure their subsequent removal (FIGURE 5).

Even at this point the calculus may be dislodged by direct palpation. If this is still impossible, the probe is reintroduced and directed firmly against the region of the papilla to determine the direction of the duct so that a small incision may be ...

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