Sometimes it is impossible to dislodge a calculus from the region of Vater's papilla by careful and repeated manipulation, and a more radical procedure is followed. Under 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 12). After the peritoneal attachment has been incised with long, curved scissors, 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 13). 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 14). 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 to expose Vater's papilla (Figure 15).
Since 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 will proceed directly to choledochoduodenostomy (Plate 100).
By exerting gentle pressure on a uterine sound or a biliary Fogarty inserted in to 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 to 4 cm long is made over this area, parallel to the long axis of the bowel. 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 15). 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 made directly parallel to it (Figure 15). This incision enlarges the papilla so that a calculus can either be expressed or be removed with fenestrated stone forceps (Figure 16). Following this, the patency of the common duct is ascertained by introducing a small and soft red rubber catheter (8 French) into the opening of the common duct and downward through the papilla (Figure 17). Any bleeding points from the incision into the papilla are controlled by fine 0000 interrupted absorbable sutures (Figure 18). The pancreatic duct must not be occluded by these sutures. No effort is made to reconstruct the papilla to its natural size, the opening being allowed to remain enlarged as a result of the incision. A sphincterotomy or sphincteroplasty can be performed through this exposure. These procedures involve the pancreatic duct as well as the common duct.
The small gauze sponges that plug the duodenum are withdrawn, and the intestine is closed. The bowel is closed in the opposite direction from that in which the incision was made. This avoids constricting the lumen of the bowel (Figure 19). The duodenal wall is sutured with interrupted 0000 silk sutures, starting at the angle adjacent to one of the Babcock clamps. The serosa is reinforced with a layer of interrupted Halsted mattress sutures of 00 silk (Figure 19). This closure must be watertight and secure to avoid the complication of duodenal fistula. A T-tube catheter is introduced into the common duct, and the duodenum is distended with normal saline to make certain that there is no leakage. A No. 14 French T-tube is then directed into the initial opening of the common duct, and the technique from this point on is observed as described in Plate 100. A closed-system suction catheter made of Silastic is inserted down past the foramen of Winslow into Morrison's pouch in all cases and remains there until there is no danger of duodenal fistula. It is advisable to bring the common-duct catheter and the drain out through a stab wound lateral to the incision (Figure 20). It is safest to avoid clamping the common-duct catheter, permitting it to drain into a sterile gauze sponge until it is attached to a drainage plastic bag. The bile is cultured for bacterial content and antimicrobial sensitivities.
The abdomen is closed in the routine manner (see Plates 7 and 8).
Constant gastric suction is employed for 24 to 48 hours. The fluid balance is maintained by the administration of Ringer's lactate solution in daily amounts of approximately 2,000 mL. The common-duct catheter is connected to a sterile drainage bag. Every effort is made to avoid pulmonary complications. In the presence of jaundice with a bleeding tendency, blood products and vitamin K may be required. The drain is removed in 24 to 48 hours, and the patient may be out of bed on the first postoperative day. Liquids and food are permitted as tolerated. The common-duct catheter, which usually drains up to 500 mL of bile in 24 hours, is removed in 10 to 14 days after a normal cholangiogram with antibiotic coverage is obtained. Attention to the caloric intake, especially in the elderly poor-risk patient, is essential.