RT Book, Section
A1 Ellison, E. Christopher
A1 Zollinger, Jr., Robert M.
A1 Pawlik, Timothy M.
A1 Vaccaro, Patrick S.
A1 Bitans, Marita
A1 Baker, Anthony S.
SR Print(0)
ID 1187822204
T1 Common Bile Duct Exploration, Transduodenal Technique
T2 Zollinger’s Atlas of Surgical Operations, 11e
YR 2022
FD 2022
PB McGraw-Hill Education
PP New York, NY
SN 9781260440850
LK accesssurgery.mhmedical.com/content.aspx?aid=1187822204
RD 2024/04/20
AB Sometimes  it  is  impossible  to  dislodge  a  stone  impacted  in  the  ampulla  of  Vater  by  careful  and  repeated  manipulation,  and  a  more  radical  procedure  is  necessary.  In  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  1).  After  the  peritoneal  attachment  has  been  incised,  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  2).  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  3).  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  expose  the  ampulla  of  the  papilla  (FIGURE  4).