Plate 100

This is a procedure favored by many, especially in place of the transduodenal approach for stones impacted in the ampulla. As overlooked common duct stones are identified or reformed, the efficacy of their removal by endoscopists and interventional radiologists has improved. Large common ducts may be associated with symptoms, especially in the elderly. A dilated common duct with recurrent bouts of cholangitis associated with diverticuli with or without stones is an indication for this procedure. Strictures of the lower common duct following previous biliary surgery can become symptom-free after choledochoduodenostomy. However, the procedure should not be considered for a nondilated common duct, malignancy of the lower end of the common duct, recurrent pancreatitis, sclerosing cholangitis, or inflammation involving the proximal duodenum. 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. The common duct should be at least 2.4 cm in diameter.

Liver function studies are evaluated, and consultation with an endoscopist and interventional radiologist 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. If cholecystectomy has been performed in the past, the incision can be made in the area of the previous operation. 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 is taken and a needle aspiration of bile from the common duct is obtained for culture and 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, especially if stones are present. The cystic duct is palpated for calculi and the common duct 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.

The anterior aspect of the common duct is cleaned as far down as possible. The surgeon should not be tempted to perform a convenient side-to-side anastomosis between the dilated common duct and the duodenum as the resultant small stoma dooms the procedure to failure. The secret of success is related to the adequate mobilization of the duodenum, the adequate size of the stoma, and finally the triangularization of the anastomosis in accordance with the technic of Gliedman. This type of anastomosis decreases the potential for the development of the sump syndrome due to the collection of food particles and calculi in the blind segment of the lower end of the common duct.

Before making the incision, the mobilized duodenum with a Babcock instrument is brought up alongside the common duct to be certain the anastomosis will be free of tension (Figure 2).

An incision about 2.5 cm long is made carefully in the middle of the common duct below the entrance of the cystic duct. The location for the anastomosis obviously will vary depending upon the anatomy presented. A slightly smaller incision is made in the adjacent duodenum in a longitudinal direction.

It should be remembered that the early success of this procedure may rest upon the accuracy of the right-angle approximation of the vertical incision in the common duct to the transverse incision in the duodenum.

Usually three traction sutures (A, B, and C) are placed to ensure that the vertical incision in the common duct will be similar in length to the transverse incision in the duodenum. Special attention must be given to the placement of the first suture (midpoint A), which involves the midportion of the incision in the duodenum and the lower angle of the incision in the common duct. The suture passes from outside to lumen at the inferior angle of the incision in the common duct. Similar sutures (angles B, C) are placed through either end of the duodenal incision (Figure 3). (These angle sutures pass from either end of the duodenal stoma fissure from outside to inside and from inside to outside in the midportion of the incision in the common duct.

Traction on these angle sutures (B, C) verifies the triangularization of the stoma in the common duct. Delayed absorbable or nonabsorbable polypropylene sutures may be used. Silk is to be avoided as it can result in a focus for infection or stone formation. The proper placement of these early sutures ensures the subsequent accuracy of the anastomosis. When the posterior row is completed, all sutures are cut except the original angle sutures (B, C) (Figure 4).

Before closing the anterior layer, a guide traction suture (midpoint D) is passed from outside to inside the midportion of the duodenal opening to inside to outside the apex of the longitudinal suture in the common duct. Traction on this suture ensures a more accurate placement of the interrupted suture in closing the anterior layer bile-tight (Figure 5). The final three or four sutures in the anterior row are used for traction as each side is tied (Figure 6).

An additional suture is taken at either angle to affix the duodenum either to the capsule of the liver laterally (x) or to the hepato-duodenal ligament medially (x′) (Figure 7).

The plateau of the stoma is tested by finger compression against the duodenal wall (Figure 8). The anastomosis should be free of tension and the angles secure. A closed-suction-system Silastic drain may be placed lateral to the anastomosis and down into Morison's pouch.

Closure of the abdominal wall is accomplished in a routine manner.

Antibiotics are given. If there is an insignificant output from the closed suction drain, it is removed after a few days. Nasogastric suction may be indicated for a day or so. A liquid diet is advanced as tolerated. Liver function tests should be restudied during the postoperative recovery period.