wAtlas of © ey Surgery Phe. %) Volume: I Emilio EtalaVolume 1 38 1 4 Pot 118 SURGERY OF THE HEPATOBILIARY TRACT AND PANCREAS FEUER OB EAE Section A A BBSb Surgery of the Biliary Tract ABM 1 Surgical Anatomy of the Extrahepatic Biliary Tree ES IB 5) 3 9 Sh MR 3 2 Cholecystectomy aD BRE 33 3. Cholecystostomy Fn Ret 105 4° Exploration of the Common Bile Duet Wa RE uy 5 Choledochoduodenal Anastomosis WE tenon 209 6 Repair of Surgical Lesions of the Common Bile Duet FLAPS AR HA . 224, 7 Cystic Dilation of the Common Bile Duct WLS aa HE 201 8 Caroli Disease FRA 315 9 Laparoscopic Cholecystectomy ORE FI a OD A 327 Section BoB BSE Surgery for partal Hypertension 18k aG EERE RS Sh LF A 10 Portal Hypertension Tsk Eee 367 11 LeVeen Peritoneovenous Shunt LeVeen BYARD BATH 433 12 Transjugular Intrahepatic Portosystemic Shunts. (LLP.S.) BSE TBSP A(T. P.S) 465 Section CC #65h Surgery of the Pancreas ERE CONTENTS 8B 13. Surgery of the Pancreas PARNER 467 14 Surgical Treatment of Pseudoeysts of the Pancreas Re Heme ET 481 15 Surgery for Chronic Pancreatitis PR FE RRM HD SKA 523 16 Pancreaticoduodencetomy We es HR ss1 17 Surgical Treatment of Pancresticoeutaneous Fistulas RS a ER eT 785 18 Surgery for Carcinome of the Pspilla of Vater op SHG Ak IE A 787 19 Surgical Trestment of Functional Iasulinomas hy 2 A AR HE 819 Pert L982 SURGERY OF THE STOMACH AND DUODENUM, FA ER Section DD -#K4E Anatomy E19 20 Surgical Anatomy of the Stomach end Duodenum At aes Oo Oe 859 Section EE 8B} Hiatus Hernia HEFL 21 Sliding Hiatal Hernia and Gastroesophageal Reflux Sab He PERT A A PT ee 899 22 Laparoscopic Surgery of Esophageal Hiatus Hernia REMARK 1001 Section FF 84h ‘Surgery of the Stomach and Duedenum, Wt SER 23° Surgical Treatment of Peptic Gastroducdenal Uleers S+ aM eT RT 1017 24 Gastric Drainage and Pyloroplasty BSL eR uate TR 1077aM CONTENTS: Volume Tt Sue Gastojejunostomy, Reka 26 Gasirostomy ReOk 27 Gastrectomy BRA 28 Dissection and Closure of the Difficul: Duodenal Stump HE bE t+ Ha 1237 29 Finsterer-Bancroft-Plenk Exclasion Gastrectomy Finwerer-Bancroé-Pleak FW RATA 1271 30) High-Lying Gastric Ulcers; Cardiac or Subeardiac 1101 1128 1173 PR AE RT 2283, 31 Gastric Uleers Penetrating the Pancreas and Tnferior Surface of the Liver ARG TA ET 1299 32 Surgical Treatment of Bleeding Gastric and Duodenal Uleers Ei Hs EAI B17 33 Perforated Gastroduodenal Uleers Baie mea, 1344 34° Complications of Gastric Surgery EAI ae BH 35 Uncommon Complications of Gastrie Surgery SF SLA FAI A 1383 36 Surgical Treatment of Gastric Diverticula Rea I AT 1401 37 Surgery for Benign Gastric Tumors AEA USSR 1409 38 Surgical Treatment of Cancer of the Stomach me NT as 39° Jejunal Patch for Duodenal Injury or Fistula SAGA ST A AS 1541 40. Superior Mesenteric Artery Syndrome HE ROE ab BE A AE, 1547 AL Duodenal Divertieule-Extraluminal Diverticula Fat RE 1561 42 Serosal Patch and Billroth Ml Gastrectomy: im the Treatment of Traumatic Lesions or Fistulas of the Duxlenum Tt BS eA MIT HR FM A th Han He 1645 Port fl 9°38 SURGERY OF THE SMALL INTESTINE, COLON, RECTUM, AND ANUS ie Ni ERG RUA ER Seotion GG ASE Small Intestine 8% a7 49 50 51 52 53 58 37 58 59 61 Surgery of the Small Intestine AG IOS E A Recurring Intestinal Obstruction Dus to Postoperative Adhesions AES RE Jejunostomy sear Meckel’s Diverticulum, RBS 1651 1689 1699 Section HH abst Colon, Rectum, and Anus 65 NT Surgical Anatomy of the Colon PRBS ODN RL ERIE Surgical Anatomy of the Reetum and Anus 2B ALL Th Be Colectomy for Cancer SAIS IBAA TT SR Right Radical Hemicolectomy HL EE HA BOR Left Radical Hemicolectomy Hen ORR Colon Resection with Mechanical Anastomosis ‘BAT PL a Hey Colonic Resection and Anastomosis with Biofragmentable Ring (VALTRAC) Je i SCHEER (VAL TRAC) (BD) Ban Laparoscopic Respction of the Colon SLR OF 2 SO AS Appendectomy WOE Bi A Laparoscopic Appendectomy FM eR ‘Transverse Colostemy and Closure PAGER MMAR Cecostorny Wie OR Surgery of Cancer of the Rectum FGM ah BAR Ulcerative Colitis HE Bs ae Croba’s Disease OPE I He Surgery of Non-neoplastie Anorectal Diseases SE MRE PE AL 1 Le 9 Mh S is 3 a7 73 14s 1873 wut 1021 1943 1987 1995 2038 2019 223 2201 2308 INDEX #31 iPart! Surgery of the Hepatobiliary Tract and PancreasSection A Surgery of the Biliary Tract CHAPTER OL Surgical Anatomy of the Extrahepatic Biliary Tree Guy de Chauliae (1300-1368). a famous surgeon from Avignon, France, stated that “good surgery cannot be performed without knowing anatomy.” This knowledge of anatomy is fundamentally important in surgery of bile ducts. The billary tract surgeon confronts a situation of, innumerable anatomic variations, which may present at the hepatic hilum and extrahepatic bile structures, The surgeon must be thoroughly familiar with the normal anatomy and with the more frequent variations that occur, Before ligating or dividing a structure it must be precisely identified to avoid dire consequences. GALL BLADDER AND CYSTIC DUCT ‘The gall blader is located on the inferior surface of the liver and held to its bed by peritoneum, The dividing line beaween the right and left lobes of the liver passes through the bed of the gall bladder. The gall bladder is 2 pear-shaped sac 8 (0 12 em in fengh and 4 to 5 em in maximal diameters, with a capacity of 30 to 50 mL. When distended, however, it may reach a capacity of some 200 mt, The gall biadder serves the Function of receiving the bile and concentrating st. It is normally bluish in ‘color, a combination of its translucent walls and the con- tained bie. ‘This translucence is lost when the walls are opacified by inflammation, ‘The gall bladder is described as divided in three seg- ‘ments, which are, however, without precise demarcation: the fundus, the body, and the infundibulum. 1. The fundus of the gall bladder is that part which pro- jects beyond the anterior border of the liver and is completely covered with peritoneum. ‘The fundus is the segment of the gall bladder thar becomes palpa- ble when the gall bladder is distended. ‘The fundus projects onto the anterior abdominal wall at the ine4% SURGERY OF THE HEPATOBILIARY TRACT AND PANCREAS tecsectiin of the ninth costal carilage with the lateral order of the right rectus muscle, although numerous variations occur 2. The body of the gatl bladder follows the funduis, and its diameter diminishes progressively more: distally. "The body is nor toxaliy covered with peritoneum; the peritoneum. binds it to the inferior surface of che liver, Thos the inferior surface of the gall bladder is, covered by peritoneum while the superior surface is ia contact with the inferior surface of the fiver, from, which its separated by a layer of areolar connective tissue through which biood vessels, lymphatics, nerve fibrils and, occasionally, accessory hepatic chucts traverse. At cholecystectomy, the surgeon should enter and exploit this areolar cleavage plane. This will permit bloodless susgery. When the cleav- age plane has been obliterated by disease, the he- patic parenchyma is frequenily scaumatized and bleeding results 3. The infundibulum, the third portion of the gail biad- der, follows the body with diminishing diameter and '8 covered by peritoneum. It is within the hepato- duodenab ligament and usually protrudes anteriorly ‘The infundibulum is referred to 2s Hartman's pouch, but we believe that Hartmann’s pouch is the result of 4 pathologic process consequent 10 im- paction of a calcutus at the inferior infundibulum or in the neck of the gall bladder, This in uum pro- duces dilation of she infundibulum and this dilation resus in the formation of the pouch, The pouch, in tur hinders the cholecystectomy owing to the adhesions it provokes to the cystic or the common duct, Hanmann's pouch is to be considered 2 patho- logic alteration insofar as the norsmat infundibulum does not have the form of a pouch, The gull bladder consists of @ layer of tall epithelial cylindrical cells and a thin fibromuscular layer consist- ing of longituding), circutar, and oblique muscle bers plus fibcous tissue covering the mucosa, The gall biad- der has no submacose nor muscularis mucosa, It has AG mucous glands and occasionally may present scant mucous glands. which may be more numerous in cases of inflammation, The mucous glands are located alawost exclusively in the neck, The fibromuscular layer is covered by a layer of areolar connective tissue through which blood ancl lymphatic vessels end nerves traverse. This is the plane to be sought to perform a subserosal cholecystectomy. ‘This areolar plane is in continuity with that which separates the gall bladder from. the liver at the hepatic bed. The infendibulum is in conunutty with the neck whose length is 15 10 20 am and angles acutely upward with the angle opening supericrly, CYSTIC DUCT ‘The cystic duct joins the gall bladder and the hepatic Suct to form the choledochus. 18 4 f0 6 inm long, ak though it may measure up to 10 t0 12 em, It may. be short or even nonexistent, The proximal diameter of the cystic duct is usually 2 19 25 mm, somewhat smelter than the distal diameter, which is some 3 mm, Viewed from the outside it appears irregular and coavokuted specially in its proximal half or two-thirds owing to the prerence of Helster’s valves, Viewed ftom the Inside, it presents Hels- ter's valves, which are semilunar and present in iterate sequence giving the impression of a continucus spiral ‘This is inexact, however, since the valves are individually separate from each other. Heiste’s valves regulate the flow of bile between the gall bladder and. the biliary pase sages, The cystic duct usually ‘oins the hepatic duct in the superior half of the hepatodvodenal ligament, usually at the sight border of the hepatic duct and usually at an acute angle, thus forming the eystohepatic angle, The cystic duct may enter the common duct perpendicularly The cystic duct may also join the hepatic duct after cours ing parallel to the hepatic duct joining it behind the first portion of the duodenum, in the pancreatic area, and even near to or at the papilla forming a perallel juncuon, It may join the hepatic duct in front or behind the hepatic duct, entering it, not on the right side of the hepatie duce, but on iis left border or its anterior wall, This rotation about the hepatic duct would be descnbed as a spiral union, Mitizei has called this variant a banding ys duct, This may give rise to the hepatic syndsome of Miizzi (27, 29), Rarely the eystic duct enters the right or isft hepatic duct. HEPATIC DUCT The biliary ducts osiginate within the liver as bile canal culi that receive the bile excreted by the hepatic cells and join among themselves, forming larger and larger ducts, giving rise to the ight and feft hepatic ducts frora the sight azd left tobes of the liver respectively. The right andl left hepatic ducts join to form the common hepatic duct, usually extrahepatically The right hepace duct is generally more inirahepatic than the left. The leagth of the common hepatic duct is very variable and depends on the evel at which the left and sight hepatic duci join. The length of the common hepatic duct aiso de- pends on the level of its union with the cystic duct 1 form the chotedochus, The common hepatic duct is usti- ally 2 to 4 cm long, although a length of 8 cm is not ine frequent. The diameter of the common hepaiic and the commen bile duct is usally 6 to 8 mun, The normal di- ameter may be up to 12 mm, However, ducts of normal diameter may harbor calculi as seen in recent cases(27, 30). There is obviously aa overlap of normal and pathologic common ducts as to their size and diameter Previously cholecystectomiaed pitients may facrease the diameter of ther choledochus and so may the elderly. The hepatic duct 3s covered with high cylindrical ep- ithelium over a lumina propris that contains mucous glands. A fibroelustic tissue layer covers the mucosa and conuins some muscular bers. Minzzi deserihed a sphincter at the distal portion of the hepatic duct. Be- cause no muscle cells were found, he labeled ita func- sional sphincter of the common hepatic duct (27. 28, 25, 32), Lang (23), Geneser (39), Guy Albot (393, Chikiar (40, 11D, and Hollinshead and others (19), have demon- strated muscle fibers in the hepatic duct. To demonstaate these muscle fibers, it is essential 10 proceed immedi- ately 1 Axation of the tissue upon obtaining the sam- ple. since autolysis rapidly supervenes botit in biliary and ia pancreatic ducts, With these precautions in mind, ‘ve have confirmed wich Dr. Zuckerberg the presence of uscle fibers in the hepatie duet CHOLEDOCHUS The choledochus i 5 to 15 ¢m in length (usually 8 to 10 cm), I is situated, tise the common heputic duct, at the fee border of the hepatoduodenal ligament. To its feft and in the sme anterior plane‘is the hepatic artery. ‘The ponal vein is in a posterior plane and cleser to the he= patic anery thaa to the choledochus. The cystic duct joins the hepatic cluct generally superior to the rst postion of the dirodenum. The choledochus passes behind the frst portion of the duodenum, continues downward and to the right along « groove of tunnel provided by the head of the pancrews, and enters the second postion of the slucclenim along, the internal {lesser curvature) portion of the duodenum and at an angle of 43 degrees, The choledoches enters the wall of the duodenum and joins the pancreatic duct, forming a common channel that ‘cmpties through the duodenal papilla ‘The common duct may be described in four segments: 1. Supraduodenal, usually 20 mm long, This is the seg- ment more readily accessible at surgery and with, the lower hepatic duet provides access for choledo- chotemy and biliary tract exploration (39) 2. Retroduodenal segment, 15 to 20-mm in length, 3 Infraduodenal extrapancreatic segment, 20 10 30 mm in length, whick courses along the head of the pan- eres in 2 groove or tunnel to reach the duodenum, at its second portion, A cleavage plane between the choledochus and the pancreas can usually be found because the pan- creas and choledochus do not adhere to each other except in cases of chronic pancreatitis in the area of Surgical Asatomy of the Bxerahenatic Bilay Tee & the head of the pancreas, In these cases itis quite impossibie to separate the choledochus and the pan- creas, and the choledochus may even be obstructed by the pancreatic thickening and fibrous tissue inft- tration, If the situation of choledochal-pancreatic fi sion does not exist, reisopancreatic choledochotory may be performed to temove an impacted calculus that has not been removable from above nor by transduodena? sphincterotony. 4 Intraduodenal or intramural Segment. 4s the chote- Gochus traverses the wall of the duocenar its cal- iber diminishes considerably and is walls get thicker. This is to be Dome in mind when interpreting chol- angiography. Fusthermore, at operative cholangiog- raphy the dye that has passed into the duodenum, can give tise to superimposition of shadows, hindes- ing a clear view of the intramural segment of the choledochus. In these cases films should! be cepeated aad a clear view of the terminal choledochus ob- tained, ‘The length of the intramural choledochus is very variable bus always mote than the thickness of the duodenal wall. This is explained by the oblique trajectory of the choledochus as it traverses the duodenal wail, The length of the tansduodenal choledochus is 14 to 16 mm (39). During its intra ‘mural path the choledochus and the pancreatic duct join in various forms, These may be described as oc- curring in three ptineipal manners (18, 21, 22, 48), as follows: 1 The choledochus and the pancreatic duct join shorly alter penetrating the wall of the duode- num sharing @ short coramon tract. This is the more frequent occurrence. Tl, Both ducts course in parallel fashion, in contact but not joined, emptying separately into the duo- denal papilla. Occasionally the pancreatic duct may empty 5 to 15 mm below the papilla. UL ‘The pancreatic duct and the cholecochus join at a higher level before entering the duodenal wall forming a common channel longer than usual, Only in few occasions does the union of Type or “Type III present a dilation giving rise 10 being des- ignated as aa “ampulla” (10, 11, 16, 18, 48, 50). HISTORICAL REVIEW OF PAPILLA OF VATER AND AMPULLA OF VATER Abraham Vater, in 1720 (49), gave a lecture at the Univer- sity of Winenberg, Germany, tided “Novus bilis divemticu- Jum,” in which he described 2 diverticulum localized at the distal end of dhe choiedochus. Vater thus described a diverticulum of the choledochus, a most rare instance of choiedochocele (10, 50). Vater searched for another such ise, but was not successful in nding one (10, 50), Vater6 SURGERY OF THE HP: never made reference so the papilla, nor did he describe the ampulla that beats his name. However, in the medical literature both the papilla and the ampulla bear his name. What is called the ampulla of Vater is the duct formed by the union of the choledochus and the panereatic duct as these pass through the wall of the second portion of the duodenum to empty at the papilla, This generally short but occasionally longer joined segment fas the configura ‘don of a duct and not of an ampulla, This duet ean dilate when the papilla is obstructed by inflammation or by an impacted stone. It is probable that the duct may acquire a larger diameter “post montis” owing to autolysis of the choledochus and pancreatic duct (10) without obstruc- hon. We believe, a8 other authors do, that the term “amn- pulla® should not be used because what is observed is a duct and not an ampulla, The enonym "Vater" should also not be used, since he never referred to it (0), Some au- thors believe that the error in naming it ampulla of Vater arose from Claude Bernard (1, 10, 11, 50), who, in writing, his book in 1856, quoted Vater as saying "ampoule con mune nommeé ampoute de Water,” and spelling Vacer wich 2 “W" inswead of with a "W." Vater never referred to the papilla chat bears his name. ‘The papilla was first deseribed by Sir Francis Glisson in England in 1654 (15) in che first edition of his: book Anatomie Hepatis, the second edition of which was pub- lished in 168i (3-5, 15). Some authors (48) acribure the fit description of the papilla 10 Gottitied Didloo of the Hague in 1685 (2), Other authors attribute it to Giovanni Domenico Santorini (42) in 1724, that being the weason ‘why in some texts the duct called the papilla of Santor Santorini did make an excellent description of dhe papilla jn the dog, sheep, and ox, but he was noe the fest w de- scribe it, Suntorini cid not add a drawing to his description, The sphincter of Oddi was also frst described by Sic Hrancis Glisson in 1654, when he described the papilla G3, 4, 5, 15). In his description Gtisson describes the annular muscle bers éf the terminal choledochus affieming that these muscular fibers served to close off the choledochus to avoid reffant of duodenal content. In 1887 G36), Ruggicrs Oddi also described the terminal sphincter of the choledochus and related it to biliery physiology. Thus we find that the papilla described. by ~ graphic image of the distal ead of the common bile duct An ackltional 5 mb, of radiopaque substance are then ine jected to see the rest of the common bile duct. lf the comoa bite duct is dilated, one shoukt inject a greater amount of radiopaque substance. The radiopsque sub- suunce should be infused after diluting it 16 35% hecause fer concemration may iinpele the vision of small cal uli, While the radiogeaphs are being developed, the su geon can continue with the peritonealization vf the gill bladder bed. If fitioroscopic equipment is available with an ampli- fying screen it is possibe 10 observe the dynamic fursc tioning of the common bile duct and the sphincter of Odkli. Normally the sphincter of Oddi contracts and re luxes synchronous with the connaction of the auuseular layer of the duodenum, When the sphineter of Oc is relaxed, bile and radiopaque substance pass into the duodenum, Ar the moment of contiaction, the bile oF ra digpaque substance ceases 10 pass into the duodenum. Normally the sphincter of Oddi opens from above downward and closes from below upward. An x-eay may be taken at the moment of contraction of the sphincter of Oddi, which will prevent the suxgeon from ‘observing the narrowed zone at the end of the common bite duct. This may lead the surgeon w believe hut there is spasia of the sphincter, sienosis, or an umpacted cal- culus, A second xray may clear up the diagnosis. For this reason itis important to ebtain two x-rays when the frst injection of radiopaque substance is performed. Fit oroscopic examination with image amplifier is very use- ful to study the functional satus of the sphincter ot (Oddl, If there is a permanent spasm of the sphincter, an injection of glucagon or cholecystokinin will lead to re- lexation of the spbincter, Amy! nitrate or trinitrin will have a similar action, Spasm of the sphincter of Oddi is rot usually associated with dilation of the common bile duct, whereas there is always dilation in cases of Bi sis of the sphincter of OddiOPERATIVE CHOLANGIOGRAPHY IN CHOLECYSTECTOMIZED PATIENTS If the patient has been previously cholecystectomized gperuive cholangiogeaphy should be periormed by puncture of the common duct. The puncture should be canfied out close to the site where the chotedochotsmy is to be performed, using a 21 gauge needle with a 10 mb sysinge filed with 39 cadiopaque solution, Ie is ica portant to cxery out the puncture from below upward and at an acute angle to he common duct. If the punc- ture #8 carried out at an obtuse angle or in a vertical di: rection, the posterior wail Of the common duct can be perforated, without aspirating bile and with perforation of the vena cava, with consequent confusion owing «0 ispiration of blood, The puncture should not be cated Out patie] to the duct 10 avoid perforation of one of the veins of the venous plexus, which covers the duet and is frequently very well developed, Once the punc- us heen cared out and a few ml, of bile have inated to be sure that che needle is in the duct, che radiopaque solution is injected very slowly. The amount of solution injected is related to the diameter of the duct, rarely more than 10 to 15 mL. If the cholan- giognium does not reveal a need for a choledocho:omy anc instrumental exploration of the common duct, the puncture should be closed with a 5-0 svathetic reab- sorbuble suture to close the puncture site, Collections of hile in the peritoneal cavity have beer knowa to com- plicate the procedure even though bile has not been seen at the time of the operition, OPERATIVE CHOLANGIOGRAPHY IN PATIENTS WITH TUMORAL OBSTRUCTIONS OF THE COMMON BILE DUCT Jn patients who present an obstructed common bile duct caused by carcinoma of the head of the pancreas, carci- roma of the papilla, oF carcinoma of the distal common bile duct, as weil as in strictures of the retropancreatic common bile duct caused by chronie pancreatitis, injec- sion of the radiopaque substance should be mide into “he gallbladder Priorto injection of the radiopaque substance: 4 porse-string suture is pliced in the fundus of che gall blacklee and its contents aspirated, These contents are usually thick and gelatinous. Some 50 to 80 ml of ra. diopague substance are then injected and the purse-string, suture around the puncture site closed, ieaving the ends ‘of the suture long to apply traction to the gallbladder up- ward and to the right so that the image of the galibladder will not be superimposed on that of the common bile ‘uct, The amount of radiopaque substance to he injected 42a Explorasion of the Common Bile Duet in these casesis greater because itis injected anto the gall bladderand because the entire biliary craecis generally di- hatux (22, 25, 26, 399, CHOLEDOCHOTOMY AND INSTRUMENTAL EXPLORATION OF THE COMMON BILE DUCT Instrumental exploration of the open common hile duct is performed when an operative chokmgiogram reveals the presence of shadows that suggest caicull associated or not With other pathologic changes. IF operative cholangiogra- phy is vot performed systematically on every patient ‘opening und exploring the common duct with instru. meats should be based on a series ofindications. Some of these had already been pointed out by Kelar in 1913, by Haranann in 1923, and by Walzel in 1928 (30, 39, 56, 57, 60.70.71). These indications are the following: 1. Paipable calculi in the common bile duct 2, Presence or history of jaundice. 3. History of biliary colic with fever and chills. 4. History of nonalcoholic acute puncreatitis, 5. Chronic pancreants 6, Flevated alkaline phosphatase. 7. Multiple small calcuti in the galtbladder. 8. Dilated thick-walled common bie duct, 9. Sclezatie or atrophic cholecyssts 18, Cystic duct increased in diameter. LL, Drainage of clondy bile from the cystic duet AL present, one can add (0 these classical indications the information obtained from. preoperative ultzasonog. apay svhen the biliary tract is dilated; and in some 50 to 66% of cases when ultrasonography shows calculi, espe- cially those in the common hepatic duct and less fre- ‘quently calculi in the distal common bile duct, Compuced tomography may also reveal the presence of dilation of tite biltary tree. In spite of these classical indications to open the com- mon bile duet there are somie cases in which the common bile duct is normal in caliber, there is nw history of clini- cal symptoms of calculi, and the patient can still have cal culiin the common bile duct. There can be cases in which the gallbladder contains one large calculus and has a thin cystic duet with a common bile duct of normal catiber but can still contain calculi inthe commonbile duct. There are some patients with a history of obstructive jaundice ar frequent biliary colies with fever and chills who may or ‘may not have ealeuli at the moment of surgery. Instrumental exploration of the common bile duct no matter how carefully itis performed cannot recognize the Presence of intrahepatic calculi or small or midsize calculi422 sn a dilated coramom bile duet, calculi in the papilla, and 50.0, Kehr maintained ia 1913 (60) that more thaat 50% Of patients operated upon for biliary calculi should be subjected to an insteamental exploration of the common bile duct. Zollinger (87) maintained that, when operative cholangiography is not performed, more than 40% of patients operated upon for biliary calculi should undergo aan instrumentat exploration of the common bile duct, The frequency of calcul in the common bike duct varies considersbly according to race, county, age of the pi- tient, duration of preexisting calculi, presence of acute cholecystitis, ancl so on. In the United states, the tre- quency of calculi in the common bile duct is estimated 10 be hetween 12 t0 15% (84), According to Mirizzi, in Ar- _gentina, itis some 20% (60). In the Far Fast, the frequency of common bile duct calculi is much greater. Ina revent study performed in Chinese patients immigrating into the United States (16), the frequency of common duct calcul ‘was found to be 37.2% while in immigrants that were not Chinese the frequency of common duct calculi was only 13.884, The greaterage of the patient, the greater duration of calculi, and the complication of acute cholecystitis ine creases the frequency of common duct calculi TECHNIQUE OF INSTRUMENTAL EXPLORATION OF THE COMMON BILE DUCT To perforin an exploration of the common bile duct by means of palpation and instrumentation it is indispens- able to perform the Vautrin-Kocher maneuver, To pet form this maneuver the transverse colon and sts meso~ colon is displaced doweward, exposing the distal half of the second portion of the duodenum aad the lateral sey- ment of the third portion, The peritoneum of the exter- ral border of the second portion of the duodenum is then incised, and the duodenum is mobilized with the pancreas toward the atidline, Wentfication of the com mon bile duct is usuaily easy. However, if simple traction is placed on the cystic stump it streiches the common bile duct, facilitating its recognition. In cayes of intense fi- broxis it may be necessary to puncture the common bile duct to identify it, To perform this puncture « Nu. 21 ale ber needle is attached to a 10 mL syringe. The puncture should be pestormed directing the needle from below upward, following an acute angle in relation to the he- pateduodenal ligainent to avoid perforation of the poste- rior wall of the common bile duct, which may lead the surgeon to believe that it Was a negative puncture: CHOLEDOCHOTOMY Choledochotomy is usually performed in the supraduo- dena portion of the common bile duct because this is the SURGERY OF THE HEPATOBILIARY TRAGT AND PANCREAS most accessible segment of the duct. It is important to verfy the exact location of the junction of the cystic duct with che common bile duct before opening the duet, ‘This ss becuse shere ace cases in which the cystic duct rns, partliel to the common bile duct and at times even shares one of its walls. The surgeon unay believe that he or she has opened the comnion bile duct whea in fact the cystic duct has heen opened. In some cases this in- convenience excurs more when the cyste duct runs a spinal course diver the anterior wall of the commen bile uct entering its medial border. In oiher eases incision of the common bile duct may fall (00 close to the entrance of the cystic duct tending to form real spur, leading 0 confusion Ta some patients, owing to pathilagic oF anatomic rea- Sons, itis more conveaient to perform an incision in the common hepatic cuct than into the common bile duct ‘Theauthor favors making triasverse chotedochotomy in the anterior wall of the comumon bile duct, below the en- trance of the cystic duct, for the Following reasons: 1. Exploration of the common bile duct and the papitia as well as extraction of any size caleuli. are per formed with the same certsinty as with Uie vertical incision of the common bile duct 2. In common bile ducts of normal caliber with thin walls, the opening and closure of a transverse ia ci- sion does not lead to strictures, while closure of a vertical incision ia these cases may lead to stenosis. 3. If the diameter of the common bile duct is ample, more than 20 mm, a trinsverse incision may serve to perform a choiedochocuodenastomy (21, 26, 60) his not necessary to divide the entize extent of the anterior wall of the common bile duct. Prior to in- ising the common bile duct the peritoneum that covets it should be incised if this has not previously beea done. In some cases the venous plexus cov ting part of the anterior wall of the common bile duct is very well developed and when the chele- dochotomy is perfonmed rather bothersome bleed- ing may occur To prevent this it is advisable to place some hemostatic sutures so that the choledo- chotomy will not bleed. To open the common bile duct two sutures are placed one below and the other above the line where the transverse incision will pass. These sutures should be 3 te 4 mm apart from each other. ‘The incision is then maée trans- versely, using a scalpel, while gentle traction is ap- plied to the previously placed sutures. Once the amon bile duct is open, the two edges of the in- cision and the wo angles of the incision are grasped with sutures to apply gentle traction giving greater amplitude to the opening. A venical incision of the common bite duct is preferred by the great majority of surgeons because it can be extended upward aaddownward, an extension that is hardly ever orac- iced. If one desites to make the incision vestically, we Uaction sutures are placed to the rignt and Lei. fof the anterior wall of the common bile duet and the common bile duet incised for about 15 mum. The edges oF the incision are grasped wich sutures and. gentle traction applied to amply the opening in the coinmon bile duct Vf the operative cholangiogram has shown the 21es- ence of eng oF five calcul in the common hepatic duct, malleable spoons of adequate size are used to remove the calculi. IF the patient shows numerous ¢aleuli, nearer to Ihe cholecochoromy. they have a tendency to show through the opening in the common hile duct, These cal- ull can be grasped with a Desjardins or Randall clamp. Calewlidhat are further away from the incision but palpi ble may be pushed betweva the index and thumb, lead ing then foward the orifice of the choledochotomy to be gtasped with the stone forceps. This maneuver can be peated with caleull in the common hepatic duct or in the cominon bile duct, in its retropancreatic segment, To 1e- move calculi that are farther away from the common bile duct, « malleable spoon of adequate size according to the calculi is introduced into the common bike duct andl the calculi are cemoved by the most practical ted nique, which is as follows: The spoon is introduced with the left hand, and the index and thumb of the right hand are used (© introduce the stone into the cavity of the spoon. While the spcon is being removed, the fingers of the right hand maintain the calculus in the cavity of the spoon 80 that it will not fall off into the lumen of the common bile duet. This maneuver is repeated as many times as necessary to remove all the calculi from the common bile duct, Using the same spoon, some calculi that are impacted in the papilla of Vater can be removed, In spite of what is stated in many surgical textbooks, itis rarely possible to introduce 2 Desjardins or Randall damp into the common bile duct to remove calculi ex- cept when the common bile dict is very dilated and the calcul are well formed. Calculi in the papilla of Vater that cannox be removed easily with the malleable spoon shoutd be removed through a iranscuadenal sphinctero- tomy. In some cases it is necessary w remove calculi rom the common bile duct using a Fogarty or Dosmia ‘eatheter: Caleuli that are lodged in a diverticular cavity of the distal common bile duct should no: be removed through the supraduodenal choledochotomy and should be removed drrough a transduodenal sphincceoomy. In some exceptional cases one or two large calculi may become impacted in the retropancreatic common hile duct, making it impossible or very waumatizing 10 re- nove them through the supraduodenai choledochotomy, ‘These calcuti should be removed through the setropan- creatic approach. 123 Pxploraiion of the Common bile Duct AF the operative cholangiogram reveals that there are calculi ia the intrahepatic duets, these can be removed by means of mulleable spoons, Dormia catheters of different sizes, or movlified Fogarty catheters (to remove calculi from the biliary ducts). AC times itis necessity to reson to irrigation with physiologi¢ solutions or suction t re- move sinall calculi and biliary mud. EXPLORATION OF THE PAPILLA The best way to explore the papiila of Vater iy operative cholangiogriphy. If the operative cholangiogram reveals adequate passage of radiopaque substance into the duo- denom and through the nasow segment of the distal common bile duct, which can be clearly seen, it is net necessary (o perform instrumental exploration of the papilla. If the cholangiography has in addition been per= Formed with iluoroscopy using a magnifying sereen, the sphincter of Oddi and its functional state can be better evaluated, However, if it has been necessary to pesform a choledochotomy to remove calculi in the common bile duct, an instrumental exploration of the pupilla is com- monly performed in spite of the normal anavomy and fagetion shown by the operative cholangiogsam. If ex- amination of the papilla by means of chokangiogeam re- veals an anatomic or functional abnozmality of che sphincter of Oddi or the presence of an impacted calew- lus, instrugnental exploration of the papilla is mandatory. To perforin an exploration of the papilla itis safest to use explorers with lapering olive shaped explorers made of rubber, plastic, or silk. These plastic and sill tissue ex- plorers are considered semirigid an relation. to those made of rubber, which are soit, and metallic ones, which are rigid. Metalbe explorers should be used only occa- sionally, since they may traumatize the common bike duct and the papilla, IF metallic Bakes dilacors are used Gin spe of their name, since they wore originally desiened 10 dilate the papilla), they should not be used for this purpose and only should be used as explorers, Ie is suf ficient that the Bakes 3. mm dilator pass through the papilla to consider that the papilla is not strictured. Tt completely unnecessary fo dilate the papilla, since recur- renee in a short period of time is the rule and because of ‘the possibility that traums of the papilla produces spasm, edema, hematomas, and even lacerations of the same. ‘Onthe other hand, arempts to dilate the papilla, at times Forced, may lead to dangerous false tracts. It ig also not advisable that the explorer that has passed easily into the duodenum be passed several times unnecessarily through the papilla with the object of reconfirming the Papilla’s permeability. ‘This is enough to taumatize the papilla, giving rise to spasm, elema, and congestion of the same. At the moment of instrumental exploration of the papilla itis necessary to establish if the exploring insiru-424 ment passed through the lumen of the papilla or if the papilla was pushed by the exploring instrument To perform this distinction these elements of juclyment are involved: 1. Ifthe exptorer has passed chrough the himea of she papilla, it makes the duodencl wall opposite the papilla prominent. giving the impression that it is about to perforate it if the explorer used is mecallic it produces a shiny metallic Color whieh is character- istic aad was described by Walzel in the year 1919. walzet's sign will not appear if the explorer is push ing the papilla forward 2. If the explorer passes through the papill, its end moves freely in the duodenal fumen, something that does not occur Ft pushes the papilla 3 ithe explorer passes shrough the papilla it generally descends 4 t 5 cm below the level at which the papilla is found, 4, Palparion of the explorer reveals that it is not sur rounded by tissue but lies free in the duodenum. When exploration of the papilla is performed, one aust Keep in ching that in certain patients the himen of the distal comaion bile duct dees not coincide with the lumen of the sarrowed segment of the common bile duet (39) Gintrapurietal seamend. so that the lumen of the narrowed segment has an eccentric oF lateral posi. tion with respect fo the segment of the common bile duct locaied above it and wider in diameter. As a com sequence, when the explore, which passes casil through the distal common bile duet, reaches the mar rowed segment, it buamps into the wall thar separates hoth jastead of entering directly into the lomen of this segment, which fs placed Literally, «uid makes one be- lieve that there is 2 narraving of die papilla, which is not exactly true CHOLEDOCHOSCOPY Alter having removed the calculi in the common bile duct a choledochoscopic examination can be performed contributing efficiently to verify if any calculi have ve mained in the lumen of the common bile duct before proceeding co place the tube and performing final con- trol operative cholangiogriphy. Choledochoscopic exam ination was periormed in the year 1953 (86). Choledo- choscopy not only pertaits visualization of the inside of the common hite duct and its calculi, but alse facilitates theie removal Choiedochoscopes nave been pettccted in recent years. Accessories have been added to choledocho- scopes forthe removal of calculi and for the performance of biopsies. ‘There are basically two principal models of SURGERY OF THE. JILPATOBILIARY TRACT AND PANCREAS. choledochoscopes: a rigid model and & flexible model. ‘The rigid model is composed of a longitucinal stem and another horizontal stem connected at right angle. The horizontal portion may be 4 to 6 em Jong. ‘This instru- ment is easy to manipulate and gives excellent visualiza- tion, The flexible model is more complex and somewhat ‘more difficult to manipulate, but it has the advamiage raat it can be introduced into the common hepatic duct and sts pnncipal branches. ‘This sastrument can also be inte. cuced into the common bile duct through the papilla. To he able to visualize the inside of the common bile duct sLis indispensable to dilate ic with a flow of physiologic saline during the examination (1, 5, 27, 65, 66). ‘The best application for choledochoscopy is in patients with intrahepatic lithiasis and patients with multiple stones, Some surgeons have replaced controt operative cholangiography atthe end of the procedure, througia the ‘Tube, wih choledochoscopy (13, 15). Some of the re0- sons given by these surgeons are these: 1. A-control cholangiogram with the Taube in place is Sifficult to imeerpret due to the frequent presence of air bubbles in the common bile duet. 2. Control cholangiography performed after the re- moval of calculi and exploration of the papilla fre- quently seveals spasin of the sphincier of Oddi, which makes interpretation difficuls. The first objection, the presence of air bubbles, is a technical Fault that is easy t0 avoid if habitual care is taken, In relation to the second objection, spasm of the sphincter of Oddi, itis not produced if the papilla is ex- plored very carefully. Spasm of the papilla occurs if forced dilations of the papilla are carried out or if ex- ploring instruments are passed several ines through the papill, tmumatizing the papilla, or when false tracts have been produced, Exploration of the papilla should be performed with plastic or woven silk explorers with conical ends. the papilla should never be dilated. T a 3mm explorer passes through the papilla Cis enough to show that the papilla is permeable, Choledochoscopy should be employed to perform 4 more complete explo- ration of the common bile duct but should not repiace the control operative cholangiogram, which should be perfonned every time the common duct has been ‘opened and explored (83). In recent yeurs video choledochoscopy has been added (o the methods of exploration of the common bile uct. This exploratory method permits the vision of the interior of the common bile duet by all the members of the surgical team through the television screen, greatly factltating complementation of the maneuvers berween the surgeon and his of her assistants for the removal of caleulCOMPLICATIONS OF INSTRUMENTAL EXPLORATION OF THE COMMON BILE DUCT Exploration of the common bile duet may produce le- ons, some oF then serious, if the instruments used are not managed with extreme care, particularly if they arc metalke, Exploration of the intrahepatic duct may pro- Guve lesions of the hepatic parenchyma when metallic spoons or explorers are used tse move calenli. The he- pane parenchyina may also be traumatized by Fogarty catheters or with Dormia baskess, The most serious lesions, however, are usually pro- duced when the papilla is explored. The most frequent ‘cause of tctuma to the papilla are attempts ro dilaze the papilla, whicl: may lead to faise tracts, The false tract may occur over the duodenum or over the pancteas. The sur- eon who is attempting to pass the papilla with rhe dite tor pesforares the common bile duct entering the duode: nal Iumen believing he or she has done so through the Fapilla and then continues to pass dilators of progres- sively greater diameter, believing the pupilla is being di- lated whee: in fact it s the false tract produced by the sur- Reon (8D. A more serious and a times mortal false tract seers when the explorer perforates the inferior common nite duct into the pancreatic parenchyma. "The appear ance of hile on the surface of the pancreas is indicative nf this complication and should be confirmed with an operative cholingiogram (15), It is very imporant that the surgeon realize that he or she bas produced a false tract in order to try to correct it during the surgical pro- cedure, since not doing so msy lead to loss of the pa- ent’s life. IFthe surgeon realizes that he or she has pro- Guced a false tract into dhe pancreas, he or she should immediately proceed te transect the common bile duct closing the distal end and anistomosing the proximal end of the common bile duct or preferably the hepatic duct (6 2 jejunal loop in Rowx-ea-¥ fashion (15). Belore the abdomen is ctosed, a suction drainage tube should be phiced under the liver for $10 6 days. A false tract inte the tomea of the duodenum carries fess serious vomplication and in many cases is not recognized al- Mough it occurs mere frequently than a false seact into the panencas, INTRODUCTION OF THE T-TUBE INTO THE COMMON BILE DUCT Final Control Cholangiogram Gace the calculi have been removed from the common bile duct and the jastrumental exploration and choledo- shoscopy have becn performed, a Taube is placed in the comain bile duct. The final operative control cholan Exploration of the Common Bile Duct 425 riogran: is performed with the Tstube in place, with the ‘object of verifying that all the calculi have been removed and the zadiopaque substance passes readily into the duodenum, If the cholangiogram reveals that the com- ‘moa bile duct is free of calculi and the radiopaque sub- stance passes normally into the duodenum, the surgical procedure is terminated, leaving a closed suction drainage tube in the foramen of Winslow and closing the abdominal wall. If, on the contrary, the control cholan- giogram reveals that there are residual calculi, the Tube is removed and the calculi seen in the cholangiogram are removed, The T-tube is again replaced in the common bile duct and a new cholangiogram obtained t be sure ‘hat all calculi have been removed. The surgeon should never leave 4 stone behind if at all possible, except in cases in which the patient's condition does not permit Continustion of the operation or the calculi are located in a duct fom which they cannot be removed (usually ine wahepaci). Ibis not advisable to leave cateuli that can be removed in the operation to be removed postoperatively, be they by instrumental removal or endoscopic spine. terotomy, Conditions To Be Met by the T-tube One of the basic conelitions that a T-rube must meet is that it be made of good quality rubher and that the long limp be solidly united to the short limb. Before placing the Tube in che common bile duct, traction should be xpplied to the short and the long limbs to verify that they are well joined, One should never use a T-tube made of Silastic because this material does not produce a fibrous reaction in the tissues and there is danger of leakage of bile imo the peritoneum when the cube is removed. In addition the tract produced by the long limb of the Silas- sic tube does not develop tissue reaction sufficient to de- velop a tact chat will permit removal of retained calculi Postoperatively. On the other hand, a Tube should never be smaller than 14 to 16 F to facilitate instrumen- fal removal of calcul that snay have been retained, The greater the diameter of the long limb of the Tube, the easier it is to introduce instruments 10 temove retained calculi. Por this reason Tubes are now made of rubber whose long limb is of greater caliber than the short limb. ‘The greater caliber of the iong timb is 10 facilitate re- moval of retained calculi postoperatively. The short limb should only allow the passage of bile and therefore its di ameter can be much smaller, . ‘The Tube should be prepared before it is placed in the common bile duct. To faciliate its postoperative re- ‘moval, the posterior side of the short limb should be re_ ‘Moved, that is. the T-tube should be converted so that its shor limb is a canal and not a tube. In addition the short limb that isto be placed in the common bile duct should126 nothe toe long or tov short. It should aot be too long to make drainage of bile more difficult nor toc short to be easily exttuced postoperatively. An incorrect placement ‘of the short limb in che common bile duct may lead toa series of complications, as we will demonstrate later, Placement of the short limb of the T-tube in the com non bile duct is a simple task. The short limb is grasped with a toothed clamp and placed deeply into the hepatic duct so that the entire short limb is in the hepatic duct. ts later placed in such a way that part of the short limb is in the common hepatic duct and part in the common bile duct so that the tong limiy of the ‘T-tube ‘will come to the outside through the choledochotomy. Once the T-iube is conectly pliced, the opening in the common bile duct is closed with 3-0 chromic eatgut or with absorbable synthetic material using interrupted su- tures. Once the wall of the common bile duct is closed. the peritoneum over the comanon bile duct is sutured 90 char a watertight closure is obtained. This should also be done using 3-9 chromic catgut or reabsorbable synthetic suture material, There are surgeons who do not leave tubes in pax ticats ie whor they establish that the common bite duct is free of calewki and that the radiopaque substance passes normally into the duodenum. Most surgeons, however, leave a ube in place when the common bile uct bas been opened (32, 39, 40, 39, 85). The reasons for this are these: 1. The Taube panially drains bile to the outside, which Goes not present a signiicant loss. 2. ‘The T-tube acts as a security valve so that if there is postoperstive spasm or edema of the sphincter of Odi and the pressure in the common bile ditct in creases, ta incident may occur that could lead ta the leakage of bie through the closure of the common hile duet, into the peritoneal cavity. 3. With the Tube in place it will be possible w per form postoperative cholangiography to verify that no calculi haye remained in the common duct. 4. Through the Tube tract it-may be possible to r+ move calculi retained in the common bile duct ‘The Tube should be brought our of the abdomen in the mos: ditect direction passible without curves or turns to facilitate the removal of residual calcul. if this should be necessary, ‘The author prefers to bring the Tube out through the samme incision as the surgery without ever having had a complication caused by this, Other surgeons bring the ‘Tube out through a small counter incision. In ether way the Tube should be fixed by suturing it to the skin and then taped to the abdominal wall using wide tape 10 avoid displacement of the ‘T-tibe during the tanspora- SURGERY OF THE HEPATOBILIARY TRACT AND PANCREAS tion of the patieat from the operating room or caused by some xet by the patient himself in the first postoperative hours Bile drained through the T-tube by gravity is collected in a plastic sterile bag located at the side of the bed. Af tera cholecystectomy with or without exploration of the comtnon bile «uct, a closed sublepatic suction drainage tube is left in place and brought out through the same ‘operative wound oF through a small counter incision This drainage tube is leit in place about 48 to 72 hours, If there is considerable hile Grainage, the drainage tube is tefe in place as long as itis considered necessary. MULTIPLE CALCULI IN THE COMMON BILE DUCT When. patients have many calculi in the common bile duct ane should always attempt to remove all of the cab cull in the same operative procedure. Once the calculi have been removed, choledochoscopy is useful in cases in which there are many calculi, Once the endoscopy has ‘been completed, a Tube is placed in the common bile duct and che controt cholangiogram obtained. tf calculi are still present the T-tube is removed and the retained calculi extracted. This maneuver can be repeated as many times as necessary until choledochoscopy and op erative cholangiogram reveal that there are no further calculi in the common bile duct. if in spite of all these measures a calculus is found in the cholangiogram per- formed postoperatively, this calculus can be removed shrough the fistulous cract formed by the long limb of the ‘Yeube (9, 11, 48, 51). This is the procedure of choice for the great majority of surgeons when weating mukiple stones in the common bile duct. However, when calculi arc very numerous, sume surgeons, after removing cal- cull ina systematic form, do a choledochoduodenosiomy ora sphinetezoplasry as a method of treatment in case a caleulys has been retained or calculi ceform in the com- mon bile duct (36, 44, 46, 56, 72, 73). the author be- lieves, as other surgeons (15, 32, 33, 39, 49, 60), that these prophylactic measures increase the mortality and morbidity rates even in experienced hands. Itis iogical to think that these figures will be even higher in less expe- rienced hands (15), ‘The author beliewes that bypass pro- cedures between the biliaty and digestive tract or sphinc- lcroplasty should be indicated in cases of stricture of che sphincter of Oddi, in stcicture of the retropancreatic duct, ‘or in those patients in whore the surgeon is sure be or she has left calculi in the common bile duct because he or she could not remove them, This possibility can occur in some cases of-iotrahepatic caleuls, to which we witl refer acer, Caleuli in the common bile duct, according to the great majority of authors, have migrated from the gall-