Plate 96

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.

With traction maintained on the ampulla, the cystic duct is defined by means of blunt dissection (Figure 13). A long right-angle clamp is then passed behind the cystic duct. The jaws of the clamp are separated cautiously as counter-pressure is placed on the upper side of the lower end of the gallbladder by the surgeon's index finger. Slowly and with great care, the cystic duct is isolated from the common duct (Figure 14). The cystic artery is likewise isolated with a long right-angle clamp. If the upward traction on the gallbladder is marked, and the common duct is quite flexible, it is not uncommon to have it angulate sharply upward, giving the appearance of a prolonged cystic duct. Under such circumstances, injury to the common duct or its division may result when the right-angle clamp is applied to the supposed cystic duct (Figure 15 and insert). Such a disaster may occur when the exposure appears too easy in a thin patient because of the extreme mobilization of the common duct.

After the cystic duct has been isolated, it is thoroughly palpated to ascertain that no calculi have been forced into it or the common duct by the application of clamps and that none will be overlooked in the stump of the cystic duct. The size of the cystic duct is carefully noted before the right-angle crushing clamp is applied. If the cystic duct is dilated and if it seems from palpation that the gallbladder contains calculi so small that they could pass through it easily, it is advisable to perform a choledochostomy. Regardless, an operative cholangiogram is performed routinely through the cystic duct after it has been divided (Plate 97, Figure 24). Because it is more difficult to divide the cystic duct between two closely applied right-angle clamps, a curved half-length clamp is placed adjacent to the initial right-angle clamp. The curvature of the half-length clamp makes it ideally suited for directing the scissors downward during the division of the cystic duct (Figure 16). Whenever possible, unless occluded by severe inflammation, the cystic duct and cystic artery are isolated separately to permit individual ligation. Under no circumstances is a right-angle clamp applied to the supposed region of the cystic duct in the hope that both the cystic artery and cystic duct can be included in one mass ligature. It is surprising how much additional cystic duct can often be developed by maintaining traction on the duct as blunt gauze dissection is carried out. After the cholangiogram, the cystic duct is ligated with a transfixing suture (Figure 17) or ligature, being sure not to encroach on the common duct. In general, the free length beyond the tie should approximate the diameter of the duct or vessel.

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