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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.
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Liver function studies are evaluated, and consultation with an endoscopist and interventional radiologist should be considered. Antibiotics are given preoperatively.
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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.
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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.
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The skin is prepared from the lower chest to the lower abdomen.
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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.
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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 ...