Plate 117

Gentle tension is put on the duodenum with noncrushing clamps, and a posterior row of 00 interrupted silk horizontal mattress sutures is placed (Figure 6).

Traction angle sutures are placed at the angles of the proposed opening in the duodenum. The incision into the duodenum is made slightly smaller than that in the cyst. All bleeding points are meticulously ligated with 0000 silk (Figure 6). The full thickness of the cyst wall is approximated to the full thickness of the duodenal incision, using interrupted 0000 silk sutures (Figure 7). Through the duodenal incision, adequate exposure of the ampulla of Vater can be obtained. If a sphincterotomy is considered, a small probe or French woven whistle-tip catheter, No. 10 or No. 12 French, is passed through the papilla of Vater into the duct (Figure 8). The patency of the common bile duct as well as the pancreatic duct is determined. Contrast medium is injected in a search for calculi or area of stenosis, as well as documentation of the size of the ducts. The superior margins of the ampulla are grasped by straight mosquito forceps. These clamps are placed in an anterolateral position to avoid injuring the pancreatic duct which enters on the medial side (Figure 9). A full thickness of tissue between the clamps can be excised for a biopsy. The contents of the clamps are oversewn with fine atraumatic sutures.

The mosquito clamps are applied again and include only several millimeters of common duct and duodenal wall at a time. The procedure is repeated until the opening is the approximate size of the common duct. Because of the wide range in the length of the intramural course of the ducts, the length of the incision will vary from 6 to 10 mm. The opening must be free of constriction when tested with a catheter or Bakes dilator. It is absolutely essential that one or more figure-of-eight stitches be taken in the apex of the incision to avoid duodenal leakage at this point.

The avascular septum between the lower end of the pancreatic duct and the common duct is divided after the introduction of a small catheter into the pancreatic duct. The septum should be divided in patients who have had recurrent pancreatitis (Figure 10). After hemostasis has been obtained and an adequate flow of bile observed upon compressing the gallbladder, the pancreatic duct likewise is probed. The septum between the common bile duct and the pancreatic duct may be divided if stenosis is present. A biopsy of tissue is taken from the ampulla and ductal walls at the time of the sphincteroplasty. After the patency of the ducts has been determined, the full thickness of the cyst wall and the full thickness of the duodenum are approximated with interrupted 0000 delayed absorbable suture as inverting sutures (Figure 11). The seromuscular layer of the duodenum is approximated to the cyst wall in order to provide the outer layer of the two-layer anastomosis (Figure 12). This layer is carried well beyond the margins of the interior anastomosis in order to prevent tension on the anastomosis.

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