𝗥𝗲𝗺𝗼𝘃𝗮𝗹 𝗼𝗳 #𝗖𝗕𝗗 #𝘀𝘁𝗼𝗻𝗲𝘀 & #𝗽𝗮𝗽𝗶𝗹𝗹𝗼𝘁𝗼𝗺𝘆 (Trans-Duodenal):
•Remove cbd stones by instrumentation (Randall stones forceps, scoops of several types and sizes, irrigation catheter, biliary Fogarty catheter) or extrinsic pressure by milking the stones to the upward #choledochotomy (Figs. 14.30and 14.31).
•Demonstrate ampullary patency using a small French catheter. If doubt about patency remains, use a Bakes No. 3 dilator very carefully to avoid false passage. Choledochoscopy may be helpful. Conduct repeated irrigation of the biliary ducts to remove small stones or sludge. If stones are impacted in the ampulla, papillotomy for their removal will be necessary. (Figs.14.32,14.34, and 14.35).
•Carry out duodenal kocherization. Insert balloon catheter all the way down through the ampulla. Place stay sutures of 4–0 silk at the duodenal wall in the area of the palpable balloon. •Perform duodenotomy using electrocautery Perform a sphincterotomy between the 10 and 11 o’clock positions to a depth of 2–3 mm using electrocautery (Fig. 14.41).
• Approximate the ductal and duodenal mucosa with interrupted 5–0 synthetic absorbable sutures (Figs. 14.41 and 14.42). Execute duodenorrhaphy in two layers. Place a T-tube into the common bile duct and insert a Jackson-Pratt drain.
“𝗧𝗿𝗮𝗻𝘀-𝗱𝘂𝗼𝗱𝗲𝗻𝗮𝗹 𝗽𝗮𝗽𝗶𝗹𝗹𝗼𝘁𝗼𝗺𝘆 𝗼𝗿 𝘀𝗽𝗵𝗶𝗻𝗰𝘁𝗲𝗿𝗼𝗽𝗹𝗮𝘀𝘁𝘆 𝗳𝗼𝗿 #𝗰𝗵𝗼𝗹𝗲𝗱𝗼𝗰𝗵𝗼𝗹𝗶𝘁𝗵𝗶𝗮𝘀𝗶𝘀 𝗶𝘀 𝗻𝗼𝘄 𝗹𝗲𝘀𝘀 𝗽𝗿𝗮𝗰𝘁𝗶𝘀𝗲𝗱 𝗶𝗻 𝗘𝗿𝗮 𝗼𝗳 𝗘𝗥𝗖𝗣”
𝗥𝗲𝗳: Surgical Anatomy and technique 5th ed 2021.