Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_738_Библиотеки_им_академика_М_И_Перельмана.pdf
Sphincteroplasty
Operative Indications:
Sphincteroplasty is an operative procedure that has been used for a variety of conditions in the past. For many decades it
was utilized as treatment for recurrent acute and/or chronic pancreatitis. This is now considered only a rare indication in an
unusual instance. Some surgeons feel that sphincteroplasty should be added to papillotomy of the accessory papilla when
surgically treating a patient who has recurrent abdominal pain secondary to pancreas divisum. In the past, there has been
some enthusiasm for sphincteroplasty and septotomy of the pancreatic duct orifice for the management of patients with
refractory post-cholecystectomy abdominal pain, perhaps secondary to stenosis of the pancreatic duct orifice.
Sphincteroplasty has also been utilized for calculus disease of the biliary tree. If, after a common duct exploration, the surgeon is not certain that all of the stones have been removed, some surgeons open the duodenum and perform a sphincteroplasty so that any retained stones might pass spontaneously. It is still used for patients who have an impacted distal common
duct stone that cannot be retrieved from above through a choledochotomy, or from below via endoscopic papillotomy. A
sphincterotomy is performed to dislodge the stone, and most surgeons will proceed to extend the incision and convert it into
a formal sphincteroplasty. Many biliary tract surgeons utilize sphincteroplasty if a patient is treated operatively for a recurrent
or primary common duct stone. Most of these patients however are now managed with endoscopic papillotomy.
If endoscopic papillotomy is unsuccessful and the patient requires a laparotomy, most biliary tract surgeons feel it is
important to add a drainage procedure to common duct exploration and stone extraction in patients with primary common
duct stones. Sphincteroplasty can be successfully used as the drainage procedure. Finally, at open cholecystectomy if an
operative cholangiogram demonstrates common duct stones in the face of a normal or small common duct, sphincteroplasty and retrograde common duct exploration can be used in an effort to avoid opening the common duct.
Sphincteroplasty 33
Operative Technique:
The abdomen is usually entered through a right subcostal incision. If the gall bladder is in
place, a cholecystectomy is performed. After the gall bladder has been mobilized, cholangiography is often carried out. After the decision has been made to perform a sphincteroplasty, a small opening is made in the cystic duct, and a balloon catheter is inserted into the
common duct, distally through the ampulla, and into the duodenum. The duodenum is
kocherized and, following balloon inflation, the area of the ampulla can be identified by palpation. A longitudinal duodenotomy is made over the point where the surgeon palpates the
balloon. If the gall bladder is not in place, an effort is made to palpate the ampulla through
the duodenum to locate the correct position for the duodenotomy. If the ampulla cannot be
Duodenotomy
palpated, a small choledochotomy can be performed and a Bakes dilator inserted down
through the distal biliary tree and through the ampulla into the duodenum.
1
Stay sutures of 3-0 silk are placed in the duodenum over
the ampulla. The balloon catheter is then advanced
beyond the ampulla so as not to perforate the bal-
loon when the duodenotomy is performed. The
duodenotomy is performed with the electro-
cautery (1). After the duodenotomy is com-
pleted, the ampulla can easily be seen by
identifying the balloon catheter emanating
from the biliary tree.
Balloon
advanced
34 Atlas of Gastrointestinal Surgery: Gall Bladder and Biliary Tract
Once the location of the ampulla has been clearly identified, the duodenotomy can be extended in either or both
directions for adequate exposure. Stay sutures of 5-0 synthetic absorbable material are placed at 3 o’clock and 9 o’clock
into the muscular fibrous tissue of the ampulla. Using the balloon catheter as a guide, a sphincterotomy is performed at 11
2
o’clock or 12 o’clock with the electrocautery (2).
The opening is extended three or four millimeters at a
time. Once the ampulla has been opened, the ductal mucosa
is sutured to the duodenum mucosa with a series of interrupted 5-0 synthetic absorbable sutures (3). These sutures are
Ampulla
Biliary
balloon
catheter
3
gathered in a hemostat. The retraction provides further exposure of the area.
Pancreatic
duct orifice
Sphincteroplasty 35
After the initial sphincterotomy incision, the pancreatic duct
orifice can be identified with a silver probe (4). The sphincterotomy is generally extended for 1 cm or 2 cm with further 5-0 synthetic absorbable sutures being placed to
approximate the duodenal and ductal mucosa. Finally,
an apex suture is placed when the length of the sphincterotomy is deemed sufficient. There is little sense in
making a sphincterotomy incision that is larger than the
diameter of the common duct.
The length of the sphincteroplasty incision will vary
depending upon the reason for its use. If one is performing a
sphincteroplasty merely to dislodge an impacted common duct
stone, a larger incision is unnecessary once the incision is large
enough to dislodge the stone. On the other hand, if one is per-
Apex suture
Probe in
pancreatic duct
4
forming a sphincteroplasty incision in a markedly dilated common
duct because of the concern of leaving behind retained stones, or
if one is performing the sphincteroplasty because of recurrent primary common duct stones, a sphincteroplasty incision 2 cm to 3 cm in
length may be carried out. One should be careful not to extend the sphincteroplasty incision beyond the point where the biliary tract and duodenum have a
common wall. With careful approximation of the ductal and duodenal mucosa, however,
risk of retroperitoneal or intraperitoneal leakage is virtually eliminated.
5
If the sphincteroplasty has been carried out for what are believed to be
symptoms related to the pancreas, from a stenotic pancreatic duct orifice,
a septotomy can be performed with Pott’s scissors (5). This incision can
Septotomy
usually be extended for four or five millimeters, at which point the septum
thickens as the course of the pancreatic and biliary tree diverge. Some feel
that the pancreatic and ductal mucosa should also be approximated with 5-
0 or 6-0 synthetic absorbable material.
36 Atlas of Gastrointestinal Surgery: Gall Bladder and Biliary Tract
Following the completion of the sphincteroplasty, the balloon catheter is
removed, the cystic duct is doubly clamped and divided, and the gall bladder
is removed from the operative field. The cystic duct stump is ligated with a 2-0
silk. If it has been necessary to perform a choledochotomy for insertion of a Bakes
dilator, a small T-tube should be left.
If the sphincteroplasty has been performed because of cholangiographic evidence
of biliary calculi in a normal or small common duct, to avoid the technical and
mechanical problems of exploring a small duct through a choledochotomy, we have
utilized transampullary exploration. The common duct can be explored with the
6
Ligated cystic
duct stump
same variety of instruments as one utilizes with a traditional common duct exploration through a choledochotomy. Biliary scoops, Randall stone forceps (6),
flushing through a French catheter, and a balloon catheter can all be utilized
(7). At the end of the procedure, one does not have to be concerned about
placing a small T-tube in a very small common duct. In addition, a sphincteroplasty has been performed, so if one does not retrieve all the stones in the biliary tree, the stones have a free course to pass spontaneously.
The lateral stay sutures are removed from the duodenum, and stay sutures
Balloon
inflated
of 3-0 silk are placed at each end of the duodenotomy. The duodeno-
tomy can be closed longitudinally or transversely. We generally will
close the duodenum longitudinally. It is closed in two layers; the
7
inner layer is a continuous suture of 3-0 synthetic absorbable
Sphincterolasty
Randall stone
forceps
material placed in a Connell fashion. Sutures are started at each
end and are tied in the middle. The outer layer is a row of interrupted, 3-0 silk, Lembert sutures. The duodenotomy may be
drained with a Silastic closed suction drain. This is more for pro-
tection in case the sphincteroplasty extends beyond the point
where the biliary tree and duodenum share a common wall, rather
than protection against leakage from the duodenotomy.
Side-to-Side Choledochoduodenostomy
Operative Indications:
Side-to-side choledochoduodenostomy, like sphincteroplasty, is a procedure that has been used in the past for a variety of
diseases, but only infrequently now. Side-to-side choledochoduodenostomy can be used for calculus disease of the biliary
tract if, after common duct exploration, one is unsure that the biliary tree has been cleared of stones. Performing a sideto-side choledochoduodenostomy will allow any retained stones to pass spontaneously. In the past, the most common indication for the procedure has been for primary or recurrent common duct stones. Following choledochotomy and stone
extraction, a side-to-side choledochoduodenostomy has been advocated by many for primary common duct stones to prevent recurrent stone formation or to allow recurrent stones to pass spontaneously if they do recur. Today, most patients
with primary common duct stones are treated by endoscopic papillotomy.
Patients with distal biliary strictures are particularly good candidates for side-to-side choledochoduodenostomy. A
patient with chronic pancreatitis, a distal biliary stricture secondary to scarring, and fibrosis of the head of the pancreas,
can often be managed by side-to-side choledochoduodenostomy. Some surgeons have also advocated its use for palliation
of biliary obstruction from periampullary malignant disease that is unresectable. Although there are theoretical objections
to placing the biliary anastomosis so close to the primary tumor, experience in several centers has demonstrated that this
can be an effective way of achieving palliative biliary decompression, with little risk of subsequent biliary obstruction from
tumor extension. Side-to-side choledochoduodenostomy can also be an effective operation in patients with recurrent biliary tract stones and/or symptoms from a peri-Vaterian diverticulum. Many have advocated diverticulum resection, but sideto-side choledochoduodenostomy is a safer, easier procedure.
38 Atlas of Gastrointestinal Surgery: Gall Bladder and Biliary Tract
Operative Technique:
The patient is explored through a right subcostal incision. These individuals have often had
a prior cholecystectomy and the old incision is re-entered. If a cholecystectomy has not
been performed previously, it is carried out. Most biliary tract surgeons feel that the diameter of the patient’s common duct should be at least 1
a side-to-side choledochoduodenostomy can be performed with little risk of subsequent
anastomosis stricture.
If the procedure is being performed for a primary or recurrent common duct stone, the biliary tree is usually markedly dilated, with a large, often ovoid or cigar-shaped,
brown primary common duct stone lodged distally (1).
Complete biliary obstruction is uncommon in these patients,
1
⁄2 cm, and preferably 2 cm, before
1
Cystic duct stump
Dilated common
duct
and the bilirubin is usually only mildly elevated. Likewise, if
the side-to-side choledochoduodenostomy is being performed
for an unresectable periampullary malignancy, the common duct
is also substantially dilated.
The adhesions between omentum and the undersurface
of the liver are divided. The duodenum and the extrahepatic biliary tree are exposed via both sharp and blunt dissection. Adhesions and attachments between the hepatic flexure of the colon and the duodenum are divided sharply, and
the duodenum is kocherized. Medial attachments between
the omentum and duodenum are also divided. As much of the
duodenum as possible is exposed and mobilized, so the duodenum can be brought up on top of the common duct for a tensionfree, side-to-side anastomosis. The first portion of the duodenum is
Primary common
duct store
Pancreatic duct
Ampulla
dissected off the anterior surface of the common duct for as great a
length as possible.
Side-to-Side Choledochoduodenostomy 39
Choledochotomy
Once the duodenum has been completely mobilized and the extrahepat-
ic biliary tree exposed along its anterior, lateral, and medial surfaces,
a choledochotomy is performed with the distal end extending to
the point where the biliary tree passes posterior to the first
portion of the duodenum. The choledochotomy is initially
made with a No. 15 blade. It is then extended with Pott’s
scissors (2). The length of the choledochotomy should be
2
at least 2 cm. The diameter of the common duct should be
at least 1
1
⁄2 cm and preferably 2 cm before the operation
is performed.
Once the choledochotomy has been performed, the duct is explored and any calculi
are removed (3). These patients generally will have had preoperative cholangiography performed either percutaneously or endoscopically. Thus, the exact
number of stones and their locations are often known at the time of surgery. If the operation is being performed for calculus disease, the various maneuvers that have been previously described for common duct
exploration are all carried out (refer to CBD exploration pages
XX).. Once the biliary tree has been cleared of calculi, a longitudinal duodenotomy the same length as the choledochotomy is
performed in the duodenum directly adjacent to, but at right
angles with the choledochotomy. This anastomosis is usually
performed in one layer. Although some biliary surgeons have
advocated synthetic absorbable sutures, we use 3-0 silk with
all the knots placed on the outside. We have never experi-
Common duct
stone
Duodenotomy
Apex suture
enced difficulty with calculi formation on the sutures. The apex
suture in the choledochotomy is placed first (3).
A 3-0 silk is passed from outside the biliary tree to within, and
then passed from within the duodenum to the outside and secured.
3
40 Atlas of Gastrointestinal Surgery: Gall Bladder and Biliary Tract
Lateral stay
suture
After this apex suture has been placed
through the most distal portion of the
choledochotomy, lateral stay sutures of
3-0 silk are positioned. These pass
4
This nicely aligns the duodenum and choledochoto-
from outside in at the mid-portion of
the choledochotomy, and from inside
out at the end of the duodenotomy.
These sutures are then gathered in a
hemostat as demonstrated, holding
the two ends of the suture, as well
as the mid-portion that passes
between the duodenum and the com-
mon duct (4).
my for subsequent suture placement. Interrupted
sutures of 3-0 silk are then placed, always
passing from outside in on the common
duct side, and from inside out on the
duodenal side, tying and cutting
each suture as it is placed (5).
When this layer has been completed to the ends of the duodenotomy and the mid-lateral
aspects of the choledochotomy,
the stay sutures are secured. The
anterior row is then placed by
passing the sutures first from outside in at the mid-portion of the
Lateral stay
sutures
Posterior row
5
duodenotomy, and then from
inside out at the most proximal
portion of the choledochotomy.
Side-to-Side Choledochoduodenostomy 41
This suture is gathered in a similar fashion by holding both ends and the mid-portion of the suture
in a hemostat. Again, this nicely aligns the duodenotomy and choledochotomy so that the
anastomosis can be completed. The anastomosis is completed with a series of throughand-through, interrupted 3-0 silk sutures.
The final three or four sutures of the side-toside choledochoduodenostomy are held
until all sutures are in place and then they
are secured (6).
Apex suture
6
Anterior row
This is a side-to-side anastomosis, which is
performed by pulling the first and second portions of the duodenum on top of the common
duct, and then carrying out the anastomosis. The
anastomosis can easily be palpated through the duodenum when the procedure is completed and should
be widely patent. The anastomosis is demonstrated diagrammatically in (7). The theoretical shortcomings of the
procedure are also nicely depicted. There is a segment of biliary tree that extends from the choledochoduodenostomy
down to the ampulla. It has been reported that vegetable material from the duodenum can pass into the biliary tree through the
side-to-side anastomosis and can become impacted distally, producing non-specific right upper quadrant symptoms referred to
7
as “the sump syndrome.” This is a theoretical disadvantage of
the operative procedure, but we have never seen this complication. The area of the choledochoduodenostomy can be drained
with a closed suction Silastic drain.