๐ฅ๐ฒ๐บ๐ผ๐๐ฎ๐น ๐ผ๐ณ #๐๐๐ #๐๐๐ผ๐ป๐ฒ๐ & #๐ฝ๐ฎ๐ฝ๐ถ๐น๐น๐ผ๐๐ผ๐บ๐ (Trans-Duodenal):
โขRemove 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).
โขDemonstrate 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).
โขCarry out duodenal kocherization. Insert balloon catheter all the way down through the ampulla. Place stay sutures of 4โ0 silk at the duodenal wall in the area of the palpable balloon. โขPerform duodenotomy using electrocautery Perform a sphincterotomy between the 10 and 11 oโclock positions to a depth of 2โ3 mm using electrocautery (Fig. 14.41).
โข Approximate the ductal and duodenal mucosa with interrupted 5โ0 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.
โ๐ง๐ฟ๐ฎ๐ป๐-๐ฑ๐๐ผ๐ฑ๐ฒ๐ป๐ฎ๐น ๐ฝ๐ฎ๐ฝ๐ถ๐น๐น๐ผ๐๐ผ๐บ๐ ๐ผ๐ฟ ๐๐ฝ๐ต๐ถ๐ป๐ฐ๐๐ฒ๐ฟ๐ผ๐ฝ๐น๐ฎ๐๐๐ ๐ณ๐ผ๐ฟ #๐ฐ๐ต๐ผ๐น๐ฒ๐ฑ๐ผ๐ฐ๐ต๐ผ๐น๐ถ๐๐ต๐ถ๐ฎ๐๐ถ๐ ๐ถ๐ ๐ป๐ผ๐ ๐น๐ฒ๐๐ ๐ฝ๐ฟ๐ฎ๐ฐ๐๐ถ๐๐ฒ๐ฑ ๐ถ๐ป ๐๐ฟ๐ฎ ๐ผ๐ณ ๐๐ฅ๐๐ฃโ
๐ฅ๐ฒ๐ณ: Surgical Anatomy and technique 5th ed 2021.
