Plate 98

The decision to explore the common duct depends not only on the patient's preoperative history and laboratory examination but also on the anatomic findings by palpation and inspection at the time of open operation. The presence of jaundice or a recent history of jaundice is a strong indication for exploration of the common duct. The common duct is explored if there is, on palpation, a suspicion of a stone; if the common duct is thickened or dilated; if the cystic duct is sufficiently dilated to permit stones to pass into the common duct; if the head of the pancreas is thickened, suggesting a chronic pancreatitis; or if there are one or more very small stones in the gall-bladder or cystic duct, which, because of their size, could easily pass into the common duct. More than 15 percent of patients with cholelithiasis present indications for exploration of the common duct unless a routine cholangiogram through the cystic duct is clearly negative. In approximately one-third of the common ducts explored, one or more stones will be recovered. Figure 1 depicts schematically the more common locations of calculi.

In the past, significant time was spent improving hepatic function, as it was believed that anesthesia and surgery were very hazardous in the presence of significant jaundice. Obviously, any coagulopathy must be corrected with vitamin K and blood products, while antibiotics should be given for sepsis or cholangitis. Percutaneous transhepatic cholangiography (PTHC) with retrograde catheter placement for decompression has been largely replaced by endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy. This allows stone extraction or stent placement to relieve the obstruction. Additionally, tumors may be visualized, biopsied, or studied with endoluminal ultrasound. Accordingly, the principal indication for open exploration of the common duct is the inability to clear the common duct stones and obstruction by ERCP. This may occur as a primary procedure or, more likely, after a laparoscopic cholecystectomy that failed to clear the stones with advanced laparoscopic techniques. The patient should be well hydrated and any electrolyte imbalance corrected.

General anesthesia with endotracheal intubation is recommended. Spinal anesthesia, either single-injection or continuous technique, may be used in preference to general anesthesia. Anesthetic agents suspected of hepatotoxicity should be avoided. Blood is promptly replaced as it is lost so as to avoid the development of hypotension.

The skin is prepared in the routine manner.

The incision and exposure are carried out as described for cholecystectomy (Plate 95). The peritoneal reflection of the ampulla of the gallbladder, which is continuous with the structures about the common duct, is visualized and incised with long, curved scissors. This liberates the ampulla from its position against the common duct and cystic duct (Figure 2). When this is done carefully, it is usually unnecessary to ligate any vessels. In the presence of jaundice the cystic duct is not clamped or divided, nor is the gallbladder removed until there is certainty that any obstruction in the region of the papilla can be relieved.

The size of the common duct, the thickness of the wall, the presence of inflammation, and any other pathologic findings are noted, together with the factors mentioned previously, to determine whether exploration of the common duct is necessary. Routine cholangiography through the cystic duct will decrease the number of choledochostomies. In doubtful situations the common duct is identified by its position in the hepatoduodenal ligament, by its direct relation to the cystic duct, by the presence of a vein running over its wall, and by the aspiration of bile from it through a fine needle (Figure 3). Anomalies of the structures in this location occur so frequently that careful and accurate identification of the duct is mandatory.

In order to explore the common duct, two fine 0000 silk sutures are placed a few millimeters apart in its wall just below the entrance of the cystic duct into the common duct (Figure 4). Traction on these sutures and tension on the gallbladder and cystic duct, unsevered from the biliary system until after the common duct procedures are completed, provide excellent exposure of the field (Figure 5). If the field is obscured by a distended gallbladder, however, adequate exposure is obtained by aspiration or removal of the gallbladder and closure of the liver bed. The liver margin is returned into the peritoneal cavity and retracted upward by a Richardson retractor. When the exposure is difficult, removal of the gallbladder from the fundus downward should be considered. Safer identification and ligation of the cystic artery and cystic duct may result. The field is entirely walled off with moist gauze packs, and a suction tube is placed down to the foramen of Winslow to remove the bile that escapes while the duct is being opened. The common duct is opened between the stay sutures with a sharp scalpel for about 1 cm. The opening is made parallel to the long axis of the duct, avoiding a blood vessel commonly found in its anterior wall. This opening is large enough to admit a choledochoscope or a small scoop without traumatizing or tearing the duct (Figure 5). The color and consistency of the bile are noted.

Should the cystic duct be sufficiently large to permit exploration of the common duct through it, it is opened between sutures placed just above its point of junction with the common duct.

Initial exploration is best performed with choledochoscopy. However if unavailable, the following technique provides reproducible results. The duct is held open and explored with a metal probe, such as Bakes dilator, which is directed downward to Vater's papilla and into the duodenum if possible. The patency of the papilla is determined at this time. With a finger inserted into the foramen of Winslow to give counter-resistance as the metal probe passes, a grating of metal against stone may be sensed, and a calculus may be found that otherwise might be overlooked. If a probe passes into the duodenum, it does not ensure that a calculus either is not impinged at the ampulla of the common duct or is not resting in a sacculation of the duct. A small, pliant metal scoop, such as a Cushing pituitary curet, is then repeatedly directed into the region of the papilla of the common bile duct, and any stones are removed (Figure 5). A scoop, 8 by 15 mm, with an easily molded handle is entirely adequate; large scoops with rigid handles should not be used. If a stone is impacted in a diverticulum to one side of the ampulla of the bile duct, the left forefinger and thumb may fix the stone so that it is fragmented by the scoop and can be removed piecemeal or by irrigation. The scoop is directed upward into both hepatic ducts, for small calculi may lodge in the larger intrahepatic bile ducts (Figure 1). A stone forceps may be used. Also, a Fogarty balloon catheter may be useful in extracting stones and verifying patency of the ampulla. After stone removal, a rubber catheter, No. 8 or 10 French, is inserted toward the liver, and warm saline is injected as the catheter is withdrawn. The catheter is then directed downward. A sudden increase in resistance will be encountered when it passes through Vater's papilla into the duodenum (Figure 6). Saline is gently injected, and if the tip of the catheter is in the duodenum, the duodenum will balloon out (Figure 7). Additional palpation of this area is facilitated by mobilizing the second portion of the duodenum (see Kocher maneuver, Plate 99, Figure 12). The scooping is then repeated. Once its patency has been established, no attempt is made to dilate the papilla beyond the gentle passage of a No. 12 or 14 French catheter, which can be felt clearly within the duodenum. Some prefer to inspect the lumen of the common duct with a flexible choledochoscope.

After manipulations upon the common duct have been completed, a T-tube common-duct catheter, No. 14 or 16 French, is inserted through the opening in the duct. The arms of the T-tube are usually shortened, and a wedge is excised opposite the main stem of the catheter to facilitate its subsequent removal (Figure 8). The opening in the duct about the catheter is closed securely with fine 0000 absorbable sutures (Figure 9). The suture line is tested by injecting saline through the T-tube (Figure 10). A final cholangiogram is obtained. The gallbladder is then removed as described for cholecystectomy (Plate 97).

A closed-system suction catheter made of Silastic is introduced down past the foramen of Winslow into Morison's pouch (Figure 11). The catheter and drain are brought out through a stab wound at a level that avoids acute angulation of either the drain or the T-tube (see Plate 99, Figure 20). The catheter is attached to the skin of the abdomen with a skin suture and adhesive tape. The abdomen is closed in a routine manner.

If the bile loss is excessive, sodium lactate or bicarbonate should be added to compensate for the excessive sodium loss. The fluid balance is maintained by daily administration of approximately 2,000 to 3,000 mL of Ringer's lactate solution. The T-tube catheter is connected to a drainage bag, and the amount of drainage over a 24-hour period is recorded. In the presence of jaundice with a bleeding tendency, blood products and vitamin K are given. The patient is ambulated and returned to oral intake as tolerated. The Silastic drain is removed in 2 to 5 days unless there is excessive bile drainage. The common duct catheter is removed in 10 to 14 days after a T-tube cholangiogram shows a normal ductal system. Antibiotic coverage is given for this cholangiogram and many leave the T-tube open to gravity drainage for a day afterwards to lessen the chance of cholangitis.