Townsend Courtney M.Jr., Evers B. Mark. Atlas of General Surgical Techniques: Expert Consult

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450 Section V • Gallbladder

◆ The completed operation is shown in Figure 42-18.

4. CLOSING (CHOLEDOCHODUODENOSTOMY AND HEPATICOJEJUNOSTOMY)

◆ A closed suction drain is used to drain the choledochoduodenostomy or the hepaticojeju-

nostomy in the event of bile leakage.

◆ The fascia is closed in running or interrupted fashion per the preference of the surgeon.

Absorbable or permanent sutures can be used.

◆ The skin is closed with skin staples or absorbable subcuticular sutures.

FIGURE 42 –18

CHAPTER 42 • Choledochoduodenostomy and Hepaticojejunostomy 451

STEP 4: POSTOPERATIVE CARE (CHOLEDOCHODUODENOSTOMY

AND HEPATICOJEJUNOSTOMY)

◆ Postoperative complications include bile leak, stricture at the hepaticojejunostomy, cholan-

gitis, and hematoma/bleeding.

◆ If a percutaneous biliary stent was placed before surgery, it should initially be placed to

external drainage. Before removal of the drain, the biliary stent should be capped off, inter-

nalizing the drainage.

◆ The output from the operatively placed drain should be monitored. If no bilious drainage is

observed after 4 to 5 days (and after internalization of biliary drainage if stent is in place),

the drain can be removed.

◆ If bilious drainage is noted, it can initially be managed conservatively with continued obser-

vation. Large leaks may require the placement of a percutaneous biliary drain to divert the

bile ﬂ ow externally while the anastomosis heals, if one was not present preoperatively.

◆ Biliary stents, if present before surgery or placed after, should be left in place at least

6 weeks before removal.

◆ An NG tube is kept in place the evening of surgery and removed on postoperative day 1.

◆ Clear liquids are started in 48 to 72 hours, and the diet is advanced as tolerated.

◆ The duration of stay is usually 5 to 8 days.

STEP 5: PEARLS AND PITFALLS

◆ In the past, percutaneous biliary stents were commonly placed before hepaticojejunostomy.

Many studies show that infectious complications are increased if a biliary stent is placed

preoperatively, presumably caused by bactobilia. However, if cholangitis is present preoper-

atively, a percutaneous or endoscopic stent is needed to relieve the obstruction and prevent

sepsis. Cholangitis is uncommon in malignant obstruction. The data were from patients

undergoing pancreaticoduodenectomy and have been extrapolated to hepaticojejunostomy

alone.

◆ Tumors arising at the conﬂ uence of the right and left hepatic ducts require resection of the

extrahepatic biliary tree, including the conﬂ uence, and require bilateral hepaticojejunosto-

mies for reconstruction. In this case, bilateral preoperative stents may make the small anas-

tomoses easier and prevent postoperative stricture formation.

452 Section V • Gallbladder

◆ Preoperative biliary stents may also be helpful in the event of common bile duct injury to

control leakage and make the anastomosis in a normal caliber bile duct easier.

◆ In the nondilated bile duct, it is best to perform the enterotomy in the jejunal limb before

performing the posterior row of the hepaticojejunostomy to prevent occlusion of the lumen

by excess tissue. This is not a problem in dilated bile ducts.

◆ With distal common bile duct stricture, malignancy should be considered and ruled out

before biliary bypass.

SELECTED REFERENCES

1. Cameron JL: Atlas of Surgery, vol 1. Philadelphia, BC Decker, 1990, pp 28-57.

2. Sohn TA, Yeo CJ, Cameron JL, et al: Do preoperative biliary stents increase postoperative complications?

J Gastrointest Surg 2000;4:258-267.

3. Jagannath P, Dhir V, Shrikhande S, et al: Effect of preoperative biliary stenting on immediate outcome after

pancreaticoduodenectomy. Br J Surg 2005;92:256-361.

4. Povoski SP, Karpeh MS, Conlon KC, et al: Association of preoperative biliary drainage with postoperative

outcome following pancreaticoduodenectomy. Ann Surg 1999;230:131-142.

453

STEP 1: SURGICAL ANATOMY

◆ A comprehensive understanding of the biliary, pancreatic, and foregut anatomy is critical

before performing any surgical procedure on the biliary tree, pancreatic duct, pancreas,

distal stomach, or duodenum.

◆ Figure 43-1 illustrates the normal pancreaticobiliary anatomy. Structures that must be

considered during sphincteroplasty include the gallbladder, the common bile duct (CBD),

the head of the pancreas, the main and minor pancreatic ducts, the ampulla of Vater (major

papilla), the minor papilla, and the duodenum. It is critical to understand the complex

relationship of these structures to one another, with the CBD beginning at the conﬂ uence of

the cystic duct and common hepatic duct. The CBD runs through the head of the pancreas

and drains into the duodenum at the ampulla of Vater. In most patients the main pancreatic

duct joins the distal CBD before draining into the ampulla of Vater, forming a common

channel.

CHAPTER

Sphincteroplasty

Taylor S. Riall

Liver

Gallbladder

Common

bile duct

Main

pancreatic duct

Minor

pancreatic

duct

Ampulla of Vater

Minor papilla

Duodenum

FIGURE 43–1

454 Section V • Gallbladder

◆ Figure 43-2 represents pancreas divisum, the most common congenital anomaly of the

pancreatic ductal system. Pancreas divisum occurs in approximately 6% to 7% of healthy

patients at autopsy. It occurs in up to 10% to 20% of patients with recurrent acute pancre-

atitis. Pancreas divisum results from a failure of fusion of the dorsal pancreatic duct and the

duct draining the uncinate process and head of pancreas. The result is that the major por-

tion of the drainage of the exocrine pancreas is through the minor papilla, with only the

duct to the uncinate process draining to the ampulla of Vater. The role of this anomaly in

causing pancreatitis is unclear, but it is thought to be the cause in a small number of

patients with recurrent acute pancreatitis, pancreas divisum, and a stenotic minor papilla.

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ The use of transduodenal sphincteroplasty is controversial in many settings. For many

indications it has been replaced by endoscopic sphincterotomy via endoscopic retrograde

cholangiopancreatography (ERCP). The decision to perform this operation depends on the

surgeon’s expertise, the clinical situation, and the expertise of local gastroenterologists.

◆ Transduodenal sphincteroplasty has been used in a variety of settings. The indications for

transduodenal CBD sphincteroplasty include:

◆ Calculous disease of the biliary tract not amenable to stone removal via ERCP.

◆ Sphincteroplasty should be performed if the surgeon believes there are retained stones

after CBD exploration.

◆ Sphincterotomy and sphincteroplasty can be used to retrieve stones impacted in the distal

CBD that cannot be removed with choledochotomy and CBD exploration.

◆ Sphincteroplasty can be used to explore the CBD with a small-caliber duct in which

choledochotomy and T-tube placement may be difﬁ cult.

◆ Treatment of recurrent and acute pancreatitis with ampullary stenosis identiﬁ ed and no

other cause of pancreatitis identiﬁ ed; considered a rare indication.

◆ The use of sphincteroplasty and pancreatic duct septotomy for postcholecystectomy

syndrome remains controversial.

◆ CBD sphincteroplasty and pancreatic duct septotomy are often performed with minor

papilla sphincteroplasty (see later) to ensure adequate drainage in patients with symp-

tomatic pancreas divisum.

◆ The indications for minor papilla sphincteroplasty include:

◆ Recurrent acute pancreatitis (abdominal pain and hyperamylasemia)

◆ Pancreas divisum with no other obvious cause of acute pancreatitis identiﬁ ed

STEP 3: OPERATIVE STEPS

1. INCISION

◆ The patient is placed supine on the operating table, with both arms extended out to the side.

◆ A ﬂ uoroscopy table or table with radiographic capability is needed for possible intraopera-

tive cholangiography.

CHAPTER 43 • Sphincteroplasty 455

◆ The operation can be performed through a right subcostal or upper midline incision.

◆ In addition to the abdominal wall being retracted, the liver should be retracted superiorly,

exposing the gallbladder, portal structures, and duodenum (Figure 43-3).

Common

bile duct

Main

pancreatic duct

Pancreatic duct to

uncinate process

Ampulla of Vater

Minor papilla

FIGURE 43 –2

Biliary balloon

catheter

Cystic duct

Head of

pancreas

Ampulla

of Vater

Balloon inflated in duodenum

Duodenum

Mobilized

gallbladder

Gallbladder

fossa

FIGURE 43 –3

456 Section V • Gallbladder

2. DISSECTION

◆ If the gallbladder is in place, a cholecystectomy is performed by dissecting the gallbladder

out of the gallbladder fossa, from the fundus down to the cystic structures (see Figure 43-3).

The cystic artery is identiﬁ ed and ligated.

◆ The cystic duct is then opened and a biliary balloon catheter is placed into the CBD from

the cystic duct. Cholangiography, if indicated, is easily performed at this point. The catheter

should exit into the duodenum at the ampulla of Vater.

◆ At this point the duodenum should be mobilized out of the retroperitoneum using the

Kocher maneuver. Then the balloon should be inﬂ ated and pulled back ﬂ ush to the

ampulla of Vater and easily palpated (see Figure 43-3).

◆ After palpating the balloon on the biliary catheter, the balloon is advanced into the duode-

num. Two 3-0 silk stay sutures are placed to the right and left of where the duodenotomy

will be performed. A longitudinal duodenotomy is made at the site of initial palpation right

over the ampulla of Vater (Figure 43-4). This can be done with electrocautery.

◆ The surgeon can then place his or her ﬁ nger in the duodenotomy and palpate the balloon

and ampulla of Vater. The duodenotomy is then extended distally for adequate exposure of

the ampulla (Figure 43-5).

◆ Absorbable 5-0 sutures are then placed medial and lateral to the exiting biliary catheter at

the ampulla of Vater (see Figure 43-5).

◆ Using the biliary catheter for guidance, the surgeon performs a sphincterotomy of the ampulla

of Vater using electrocautery (see Figure 43-5). This should be performed slowly, 3 to 4 mm

at a time for a total length of 1 to 2 cm. The length of the sphincterotomy will vary depending

on the indication.

◆ After the sphincterotomy is performed, the CBD mucosa is approximated to the duodenal

mucosa using interrupted 5-0 absorbable sutures. The apex suture is shown in Figure 43-6,

with several other sutures already in place.

◆ Once the CBD is opened, the pancreatic duct oriﬁ ce can be identiﬁ ed, and a lacrimal duct

probe can be placed into the duct (see Figure 43-6).

CHAPTER 43 • Sphincteroplasty 457

Balloon

advanced

Duodenotomy

Ampulla

of Vater

FIGURE 43 –4

Biliary balloon

catheter

Papillotomy of

ampulla of Vater

Ampulla

of Vater

FIGURE 43 –5

Main pancreatic

duct

Apex suture

Probe in

pancreatic duct

FIGURE 43 –6

458 Section V • Gallbladder

◆ To ensure adequate drainage of the pancreatic duct, a pancreatic duct septotomy can be

performed over the probe (Figure 43-7).

◆ In the case of pancreas divisum, the duodenotomy may need to be extended proximally on

the duodenum to identify the minor papilla. In cases where this is difﬁ cult to identify, secre-

tin can be given to stimulate pancreatic secretion and aid in identiﬁ cation.

◆ The minor papilla is small and can be difﬁ cult to cannulate. A small lacrimal duct probe

should be used and inserted atraumatically to prevent hematoma at the minor papilla

(Figure 43-8).

◆ After cannulation, a papillotomy can be performed over the probe using electrocautery

similar to performing the sphincterotomy at the major papilla.

◆ The pancreatic ductal mucosa is approximated to the duodenal mucosa using 5-0 absorbable

suture, similar to the approximation of the CBD to the mucosa after ampulla of Vater

sphincteroplasty.

◆ After the sphincteroplasty is completed, the biliary catheter can be retracted and a cholan-

giogram performed if necessary.

◆ The biliary catheter is then removed and the cholecystectomy is completed by ligating the

cystic duct distal to the ductotomy made for the biliary balloon catheter, dividing the cystic

duct, and removing the gallbladder from the ﬁ eld.

◆ The duodenotomy is then closed longitudinally in two layers. Care must be taken not to

narrow the duodenal lumen. Stay sutures of 3-0 silk are placed at the most proximal and

distal points of the duodenotomy. The ﬁ rst layer is performed with absorbable 3-0 suture

in Connell fashion (Figure 43-9).

◆ The outer layer is closed in interrupted fashion using 3-0 silk suture (Figure 43-10).

◆ A closed-suction drain is placed to drain the duodenotomy.

CHAPTER 43 • Sphincteroplasty 459

Pancreatic duct

septotomy

Common

bile duct

Pancreatic duct

FIGURE 43 –7

Main

pancreatic duct

Duct to

uncinate

process

Minor papilla

Lacrimal

duct probe

FIGURE 43 –8

Sphincteroplasty

FIGURE 43 –9

FIGURE 43 –10