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128
5. Extrahepatic Bile Ducts: Diagnosis and T reatment
5.1 Ultrasonography of the Bile Ducts
M. Birth, H.−F. W eiser
Goals and Methods
Laparoscopic ultrasonography is a practical imaging modality,
which in the hands of an experienced surgeon can largely compensate for the disadvantages of the laparoscopic technique like
loss of tactile sensation and two-dimensional visualization.
The goal of the examination is to positively identify anatomic
structures in the hepatoduodenal ligament. A decisive advan-
tage of ultrasonography is that the study can be repeated any
number of times at any point in the operation especially in
cases where the anatomy is difficult to interpret. At the same
time, the surgeon can use this method to detect gallstones and
to verify that the extrahepatic bile ducts are intact or demon-
strate major bile duct lesions.
Indications
쐌 Identification of the topography and anatomy of the hepa-
toduodenal ligament.
쐌 Identification of the intrahepatic bile ducts and of their ana-
tomic relation to neighboring structures.
쐌 Intraoperative confirmation of presence or absence of
choledocholithiasis.
쐌 Intraoperative confirmation of presence or absence of iatro-
genic bile duct injuries.
쐌 Assessment of the extent of primary biliary tumors or
assessment of the biliary system in the presence of liver
tumors.
Special Preparations and Required
Equipment
Placing a nasogastric tube decompresses the stomach and
duodenum and allows filling these organs with saline solution
to improve the transduodenal visualization of intrapancreatic
and prepapillary segments of the common bile duct. The surgeon must be proficient in conventional transcutaneous and
open intraoperative ultrasound techniques for imaging the biliary system. The following equipment is required:
쐌 Real-time B-mode ultrasound unit with color Doppler op-
tion.
쐌 Flexible-tip ultrasound probes at least 40 cm in length with a
diameter not exceeding 10 mm (for insertion through standard trocars). Only flexible-tip probes permit optimal transducer positioning.
쐌 Linear or convex arrays that provide sound frequencies of 5−
10 MHz.
쐌 Thermal printer or, preferably, video recorder for docu-
menting findings.
Anesthesia
General anesthesia.
Patient Positioning (Fig. 5.1.1)
Contraindications
At present there are no known contraindications. However, extensive adhesions on the hepatic convexity can render the ultra-
sound study technically impossible.
Surgical Risks and Patient Information
The ultrasound examination is performed during laparoscopic
cholecystectomy. The mandatory discussion of general surgical
risks involved with this procedure will suffice. Mechanical injuries to intraabdominal organs caused by the ultrasound probe
should be mentioned as a specific complication.
Place the patient supine (0 degrees), or in a slight right lateral
position to facilitate filling the right upper abdomen with fluid
as required.
Trocar Placement
Trocars are placed in a left lateral position and below the umbilicus (see Fig. 5.1.2).
Avoiding Problems
129
Ultrasound Technique
Complications
Intraoperative complications resulting from ultrasound examination have not been described in the pertinent medical litera-
ture to date. Mechanical injuries to intraabdominal organs from
the tip of the probe are possible. Such injuries must be treated
according to their location and size. To avoid such complica-
tions, any intraabdominal maneuvers with the ultrasound
probe may only be performed under laparoscopic visualization.
Regulations regarding asepsis must be strictly observed even
when using sensitive ultrasound probes. Cold sterilization alone
is not sufficient. Only strong sterile coverings should be used to
avoid perforation and contamination of the peritoneal cavity.
Gas sterilization or, better, plasma sterilization is preferable.
Avoiding Problems
Laparoscopic ultrasonography involves sophisticated techniques and requires the physician to be proficient in ultrasound
examination.
Intraluminal gas in the upper gastrointestinal tract will signifi-
cantly compromise the examination. For this reason, preopera-
tive or intraoperative gastroscopy should be avoided.
When performing the examination, the surgeon should apply
sufficient pressure to achieve acoustic coupling of the trans-
ducer and the tissue to be examined while avoiding compression of hollow or cystic structures. Hepatic steatosis or morbid
obesity can lead to unsatisfactory results. If the abdominal wall
is distended, a more favorable angle of the ultrasound probe
may be achieved by reducing the pneumoperitoneum. This
facilitates optimal probe positioning and simplifies the examination.
Step-by-Step Procedure
I Technical Preparation
Prepare the ultrasound unit and connect the ultrasound probe.
II Intraoperative Ultrasound
1. Introduce the ultrasound probe through the left lateral trocar.
2. Place the tip of the probe on the hepatic convexity and locate
the bifurcation of the hepatic duct.
3. Slowly withdraw the probe while rotating it. This provides a
continuous image of the common hepatic and common bile
ducts throughout the entire length of the hepatoduodenal
ligament.
4. Distinguish these structures from neighboring structures
using color Doppler ultrasound (optional).
5. Place tension on the gallbladder, pull it caudally and continuously, and use the liver as an acoustic window.
6. Determine the maximum diameter of the common hepatic
and common bile ducts (inside-outside method. This provides
a measurement of the wall thickness of the ducts).
7. Change the approach and advance the probe through the trocar below the umbilicus. Place the transducer on the superior
margin of the duodenum to image the intrapancreatic and
prepapillary segments of the common bile duct, respectively,
filling the stomach and duodenum with water if necessary.
8. Remove the ultrasound probe and perform the cholecystectomy using the preferred standard technique.
9. Place the patient supine (0 degrees) and in a right lateral position, and irrigate the operative site with physiologic saline so-
lution.
10. Again advance the ultrasound probe through the left lateral
trocar and place the tip of the probe anterior to the hepatoduodenal ligament to verify that the common hepatic and
common bile ducts are intact.
11. Remove the ultrasound probe and aspirate the fluid.
130
5.1 Ultrasonography of the Bile Ducts
Operative Technique
Monitor
Fig. 5.1.1 Ultrasound exploration of the
bile ducts. Position of the operating team
and equipment.
The ultrasound unit is placed on the
patient’s right and is operated by an experienced OR nurse, or the surgeon may
operate it by remote control. Use of a splitscreen imaging feature permits simultaneous visualization of the position of the
probe and the ultrasound image on the
same monitor (see Fig. 5.1.4a).
Assistant
Ultrasound unit
OR Nurse
Surgeon
Instruments
Equipment
Fig. 5.1.2 Ultrasound exploration of the bile ducts. Trocar placement.
The ultrasound probe is advanced into the abdomen through the
left lateral working trocar. To visualize the prepapillary segments of
the common bile duct, it is sometimes helpful to transfer the laparoscope/camera to a trocar placed through an additional port site
below the umbilicus.
T2
Avoiding Problems
T4
T3
131
T1
a b
Fig. 5.1.3a, b Ultrasound exploration of the bile ducts. Exposure of the
bifurcation of the common hepatic duct and junction of the right and left
hepatic ducts.
The ultrasound probe is advanced under laparoscopic vision and placed
on the hepatic convexity (a). The angled tip permits optimal tissue con-
tact. The moist surface of the organ ensures sufficient acoustic coupling.
The common hepatic and common bile ducts are located transhepatically
by slowly sweeping the transducer across the hepatoduodenal ligament.
The duct structures are then followed centrally until the common hepatic
bifurcation and intrahepatic right and left ductal distributions are located.
In contrast to transcutaneous ultrasound, the intrahepatic bile ducts can
be visualized at the frequency of 7.5 MHz as far as their secondary
branches. These structures can be distinguished from vascular structures
with the aid of color Doppler ultrasound (b).
132
a b
Fig. 5.1.4a, b Ultrasound exploration of the bile ducts. Imaging the
structures in the hepatoduodenal ligament.
The common hepatic and common bile ducts are visualized longitudinally
in successive segments by slowly withdrawing the ultrasound probe
through the trocar while rotating it. Keeping the common hepatic and
common bile duct in the image, the surgeon can scan the ultrasound
topography of the ligament. The width of the duct is measured using external diameter value and substracting wall thickness (Inside-outside
5.1 Ultrasonography of the Bile Ducts
method (a)). The cystic duct and its union with the common hepatic and
common bile duct can only be successfully visualized in about one patient
in four (a). The common hepatic and common bile duct are anterior to the
portal vein throughout their entire length. Color Doppler ultrasound is
very helpful here in differentiating anechoic structures. Applying tension
to the gallbladder shifts the inferior margin of the right hepatic lobe
further inferiorly, allowing it to be continuously used as an acoustic window (b).
a b
Fig. 5.1.5a, b Ultrasound exploration of the bile ducts. Imaging the in-
trapancreatic segments of the common bile duct.
To visualize the intrapancreatic segments of the common bile duct, the
transducer is advanced through a trocar below the umbilicus and placed
on the superior to right lateral margin of the duodenum, where it is
angled inferiorly and carefully advanced posteriorly until the intrapancreatic duct segment is imaged longitudinally (a). If the quality of visuali-
zation is poor, the stomach and duodenum can be filled with about 300−
400 ml of physiological saline solution and the duct segment in question
can be imaged in a transduodenal view. This involves placing the tip of the
probe to the right of the descending duodenum so that the transducer
contact surface faces medially (b). This method may also be used to demonstrate intrapapillary incarcerated stones.
Fig. 5.1.6 Ultrasound exploration of the bile ducts. Technique following 컄
cholecystectomy.
To avoid annoying gas artifacts in the bed of the gallbladder and to improve acoustic coupling, place the patient in slight right lateral position
and irrigate the operative site with physiologic saline solution. The central
segments of the common bile duct and the segments close to the
duodenum can now be easily visualized longitudinally by placing the array
directly on the hepatoduodenal ligament or by simply dipping the tip of
the ultrasound probe into the coupling fluid and positioning it anterior to
the ligament. By using a combination of back-and-forth movement with
slight rotation in each direction, the absence of residual stones can be
verified and the integrity of the bile duct can be assessed with ultrasound.
Narrowing due to clips including complete closure of the lumen and
complete transection of the common hepatic and common bile ducts can
be reliably demonstrated with ultrasound. Punctiform or linear defects in
the walls of the biliary system cannot yet be demonstrated with sufficient
differentiation from other tissue. In such cases, intraoperative cholangio-
graphy remains the method of choice.
Complications
133
5.2 Intraoper ativ e Cholangiograph y
A. Pier , F . Götz
Goals and Methods
Intraoperative cholangiography can be performed during laparoscopic cholecystectomy. It provides the surgeon with information about the anatomy and drainage of the biliary system
and the major duodenal papilla. Intraoperative cholangiography
is indicated in patients with a history, diagnostic signs, clinical
symptoms, or intraoperative suspicion of biliary obstruction
(generally stones), or of anatomic anomalies that impede bile
flow. It is further indicated if preoperative diagnostic imaging
studies (ultrasound and endoscopy) are inconclusive or unfeasible in the presence of strong clinical suspicions of common
bile duct stones. Ultrasound examination, endoscopy (ERCP),
and choledochoscopy may be performed intraoperatively. If the
operating team has sufficient experience, these procedures may
be used in place of cholangiography.
Indications
쐌 Intraoperative signs supporting suspicion of bile duct stones.
쐌 Detection or exclusion of ductal injuries (cholangiography it-
self can produce bile duct injuries).
쐌 Orientation and documentation of the ductal anatomy.
Whether cholangiography is regularly indicated depends on the
specific clinical considerations and the quality of preoperative
diagnostic imaging studies such as ultrasound, oral or in-
travenous cholangiography, or endoscopic retrograde cholangiography (ERC).
Alternate Procedures
쐌 Preoperative intravenous or oral cholangiography.
쐌 Preoperative and intraoperative ERC.
쐌 Preoperative and intraoperative transhepatic cholangiogra-
phy.
쐌 Intraoperative choledochoscopy.
쐌 Intraoperative ultrasound (currently under evaluation).
Complications
Bile duct puncture.
Avoidance:
쐌 Advance the catheter under fluoroscopic visualization when
using the Seldinger technique.
쐌 Use a cholangiographic catheter without a guide wire.
Corrective action:
쐌 The puncture caused by a guide wire is generally small
enough to be repaired with fibrin glue.
쐌 Place a Robinson drain if necessary.
쐌 Suture larger punctures if necessary.
쐌 Alternative: laparotomy.
134
5.2 Intraoperative Cholangiography
Step-by-Step Procedure
I Technical Preparations
Prepare cholangiographic catheter and contrast material.
II Intraoperative cholangiography
1. After exposing the structures in Calot’s triangle, make transverse incision in the cystic duct.
2. Introduce the cholangiographic catheter through an instrument trocar.
Operative Technique
3. Insert the tube into the cystic duct using a grasper or directly
using Seldinger’s technique.
4. After intubation, seal the cystic duct with a clip or balloon
catheter.
5. Inject contrast material while observing the filling pattern on
the fluoroscopic monitor.
6. Additional procedure steps depend on the specific diagnosis
and operative indication.
T2
Fig. 5.2.1 Intraoperative cholangiography. Cholangiographic catheter.
The 5-mm catheter guide tube shown here is angled 30 degrees at the tip
to facilitate inserting the cholangiographic catheter into the cystic duct.
After intubation, the balloon at the tip is filled with saline solution (see
Fig. 5.2.4) to prevent the catheter from slipping out of the duct. This also
seals the cystic duct and prevents contrast material from leaking through
the incision in the cystic duct.
T3
3
1
2
Fig. 5.2.2 Intraoperative cholangiography. Preparing the placement of
the cholangiographic catheter.
In the presence of inconclusive preoperative diagnostic imaging studies
or unusual ductal anatomy (for example where the cystic duct is grossly
distended), the surgeon can visualize the intrahepatic and extrahepatic
bile ducts under fluoroscopy.
After dissecting the cystic duct, ligate the distal (gallbladder) end of the
duct with a clip or ligature. Make a transverse incision with mini dissecting
scissors, inserted through port T2, as close to the gallbladder as possible.
One may use either the special laparoscopic cholangiographic catheter
shown in Fig. 5.2.1 or a conventional catheter. We recommend introducing the catheter through the 5.5-mm instrument trocar (located at
port T3 at the midclavicular line) since it is generally opposite the cystic
duct in orthograde orientation.
1 Common bile duct
2 Cystic duct
3 Common hepatic duct
Fig. 5.2.3 Intraoperative cholangiography. Proper and safe positioning.
When selecting the trocar for advancing the cholangiographic catheter,
note that the catheter should enter the cystic duct at a right angle and
course away from the clip. Often these conditions can be met by using the
trocar at port T3 (see Fig. 4.1.28).
While spreading Calot’s triangle with a grasper, insert the guide tube with
the conical tip directly into the incision. With its 30-degree angled tip, the
catheter can usually be easily inserted into the cystic duct.
Bibliography
1
135
.
3
.
1
.
Fig. 5.2.4 Intraoperative cholangiography. Cholangiographic catheter
with inflated balloon.
A spherical balloon in the cholangiographic catheter is inflated to seal the
cystic duct. With the catheter advanced into the common bile duct, the
surgeon can visualize either the common bile duct as far as the
duodenum or the common hepatic duct, depending on the specific duc-
tal anatomy. Withdraw the catheter under fluoroscopic visualization while
injecting contrast material until the specific anatomy of the cystic duct
has been clearly demonstrated.
1 Catheter in the cystic duct.
Bibliography
Berci G, Morgenstern L. Laparoscopic management of common bile duct
stones: a multi-institutional SAGES study. Surg. Endosc. 1994; 8:1168.
Blass CE, Seim HB. Surgical techniques for the liver and biliary tract. Vet. Clin.
N. Amer. 1985; 15:257.
Bruhn EW, Miller FJ. Routine fluoroscopic cholangiography during laparo-
scopic cholecystectomy: an argument. Surg. Endosc. 1991; 5:111.
Cameron BH, O’Regan PJ, Anderson DL. A pig model for advanced laparo-
scopic biliary procedures. Surg. Endosc. 1994; 8:1423.
Gai H, Thiele H. Sonographische Selektionskriterien für die laparoskopische
Cholezystektomie. Chirurg 1992; 63:426.
Gerl R, Apt A. Apt MK. The case against routine operative cholangiography.
Amer. J. Surg. 1982; 143:734.
Heinerman M et al. Endoscopic retrograde cholangiographic demonstration
of a double gallbladder following laparoscopic cholecystectomy. Surg. Endosc. 1995; 9:61.
Herzog U. Kocher TH, Schuppisser JP et al. Die laparoskopische Cholezystek-
tomie − Erfahrungen und Ergebnisse mit einer neuen Operationstechnik.
Schweiz. med. Wschr. 1992; 122:659.
Holzman MD, Sharp K, Holcomb GW,Frexes-Steed M, Richards WO. An alter-
native technique for laparoscopic cholangiography. Surg. Endosc. 1994;
8:927.
Huguier M et al. Selective contraindications based on multivariate analysis
for operative cholangiography in biliary lithiasis. Surg. Gynec. Obstet.
1991; 172:470.
Jakimovicz JJ et al. Comparison of operative ultrasonography and radiogra-
phy in screening of the common bile duct calculy. Wld. J. Surg. 1987;
11:628.
.
2
Fig. 5.2.5 Intraoperative cholangiography. Complication: guide wire
puncture of the common bile duct.
Using a cholangiographic catheter with a guide wire (Seldinger’s technique) entails the risk of puncturing the posterior wall of the common bile
duct with the guide wire.
1 Cystic duct
2 Common bile duct
3 Common hepatic duct
John TG et al. Preliminary experience with intracorporeal laparoscopic ultra-
sonography using a sector scanning probe: a perspective comparison with
intraoperative cholangiography in the detection of choledocholithiasis.
Surg. Endosc. 1994; 8:1176.
Joyce WP, Keane R, Burke GJ et al. Identification of bile duct stones in
patients undergoing laparoscopic cholecystectomy. Brit. J. Surg. 1991;
78:1174.
Leveilele RJ, McCann JC, Maini BS: Laparoscopic common bile duct explora-
tion. J. Laparoendosc. Surg. 1991; 287.
Lezoche E et al. Technique and results of routine dynamic cholangiography
during 528 consecutive laparoscopic cholecystectomies. Surg. Endosc.
1994; 8:1443.
McEntee G, Grace PA, Bouchier-Hayes D. Laparoscopic cholecystectomy and
the bile duct. Brit. J. Surg. 1991; 78:385.
Mirizzi PL. La cholangiographia durante las operationas de las vias biliaires.
Bull. soc. cir. 1932; 16:1133.
Morgenstern L. Halsted’s nemesis: the common bile duct. Surg. Endosc.
1994; 8:1165.
Ochs A, Sommer B, Weaz W et al. Klinischer Stellenwert von Sonographie
und Computertomographie vor abdominellen Eingriffen. Med. Klin. 1991;
86:617.
Petelin JB. Laparoscopic approach to common duct pathology. Surg. Laparos-
cop. Endosc. 1991; 1:33.
Pier A, Götz F, Ibald R, Thevissen P. Laparoskopische Plazierung einer T-
Drainage bei Choledocholithiasis. Chirurg 1991; 62:691.
Röthlin M, Bouillon B, Klotler HJ. Checkliste Sonographie für Chirurgen. In
Largiadèr F, Wicki O, Storr A. Stuttgart: Thieme; 1991.
Sackier JM, Berci G, Phillips E, Carroll B, Shapiro S, Paz PM. The role of cholan-
giography in laparoscopic cholecystectomy. Arch. Surg. 1991; 126:1021.
136
5.3 Comments on Intraopertive Cholangiography
5.3 Comments on Intraopertive Cholangiograph y
B. V. MacFadyen, Jr.
Intraoperative cholangiography (IOC) is the best test to determine the anatomy and the presence of bile duct stones.
However, in surgical practice, this technique is utilized in only
40−50% of laparoscopic cholecystectomies with a successful
cannulation rate of 85−95%. Bile duct injury can be detected
with this technique but most of the surgical dissection occurs
after cholangiography is completed and, therefore, injuries can
be missed. If bile duct stones are observed on the cholangiogram, the surgeon should be prepared to proceed to laparo-
scopic common bile duct exploration either through the cystic
duct or via a choledochotomy. In addition, choledoscopy and intraoperative endoscopic retrograde or antegrade papillotomy
can be performed for stone removal or as part of a bile duct
drainage procedure. Preoperative ERCP is more frequently performed today but the positivity rate is only 35−40%. However,
preoperative ERCP is very useful if bile duct stones are noted on
ultrasonography or the bilirubin is > 3 mg%. In addition, ERCP
also gives an excellent anatomical assessment and helps in
planning laparoscopic cholecystectomy.
In all aspects of IOC, fluoroscopy is preferred over static films
because it allows the surgeon to monitor the cystic and bile duct
filling and emptying of contrast medium into the duodenum in
real time. If there is a questionable area, this can be repeatedly
evaluated until a decision has been made regarding the area of
concern. Intraoperative ultrasound has also been used to determine bile duct anatomy and the presence of bile duct stones.
However, there is a long learning curve and interpretation of re-
sults can be confusing and inconclusive. The potential for iden-
tifying an accessory right hepatic duct or the entrance of the
cystic duct into the right hepatic duct can be diff icult to determine by ultrasonography, whereas cholangiography gives a better anatomical road map.
Occasional complications can occur during cholangiography.
The catheter or guide wire may perforate the posterior wall of
the cystic duct or the posterior or anterior wall of the common
bile duct. This problem should be recognized and treated immediately using suture or fibrin glue and the placement of a periductal drain. Rigid tip catheters and wires are most prone to
cause this problem which can be reduced with the use of a
floppy tip guide wire with a slight angulation of the tip.
However, I prefer a metal tip catheter with a 30° angled tip because it allows for rapid insertion into the cystic duct and it has
an umbrella-type mechanism which is easily inflated to prevent
leakage of bile from the cystic duct opening. With this catheter,
it is necessary to hold it during fluoroscopy to prevent catheter
twisting and possible cystic duct injury. Catheters with a bal-
loon at the tip may advance into the bile duct or be pushed out
of the cystic duct opening when the balloon is inflated. Familiarity with each catheter is important for rapid and successful
cannulation. With flexible catheters not having a balloon at the
tip, the catheter can be held in place by a loosely fitting clip
since a tight fitting clip may occlude the cholangiocatheter.
Cholangiography is best performed early in the procedure after
the gallbladder-cystic duct junction has been dissected circumferentially and occluded with a metal clip or suture. The
cystic duct incision should be partially cut transversely with microscissors immediately below this clip and cystic duct transection should be avoided. If the cystic duct is divided, the duct
should be cannulated through the end or through another anterior wall incision and a cholangiogram obtained. Excessive dissection down to the cystic duct-common bile duct junction
should be avoided so as not to injure the bile duct or the blood
supply to the bile duct that runs along the 3:00 and 9:00 o’clock
positions of the bile duct.
Insertion of the catheter into the cystic duct can occasionally be
difficult because the cystic duct is small or fibrotic, contains
stone fragments, or the valves of Heister are very competent
and prevent the advancement of the catheter. In these cases, the
cystic duct should be gently compressed from the cystic duct/
bile duct area to the cystic duct incision with a grasper so as to
extract stone fragments. Another useful technique is to dilate
the cystic duct with saline which opens the valves of Heister
and allows for successful catheter cannulation.
After the cholangiocatheter is inserted, I prefer to use a mixture
containing a 15% contrast medium use medium or solution. But
not both. Any bubbles in the tubing and catheter should be meticulously removed in order to avoid their visualization on
fluoroscopy which may look like stones in the common bile
duct. If a stone is noted on fluoroscopy, an 0.89 mm floppy tip
wire can be inserted through the cholangiocatheter and common bile duct exploration can proceed. Sometimes it is difficult
to visualize the proximal bile ducts and particularly the right
hepatic duct. To better observe these areas, the patient can be
placed into the Trendelenberg position and turned to his/her
right. Fluoroscopy allows for accurate anatomical demonstration and frequent injections will help eliminate the confusion
between air bubbles and bile duct stones.
At the conclusion of IOC, the cystic duct should be doubly
clipped or tied immediately below the incision so as to avoid
any injury to any other structures.
In conclusion, this technique can be effectively and efficiently
performed 85−95% of the time in 5−12 minutes with very few
complications.
Standard Procedure (Erlanger Method)
5.4 Intraluminal Endoscopic Common Bile Duct Exploration and
Stone Retriev al
N. Soehendra
The intraluminal endoscopic technique is the procedure of
choice for common bile duct exploration and stone retrieval.
Papillotomy Technique
By definition, papillotomy is the surgical division of the papilla
of Vater. The sphincter of the common bile duct is usually not
divided completely; the papilla is only incised as required. Ex-
tracting large stones requires an incision of maximum size;
placing an intraluminal drainage tube requires only a minimal
incision.
The papillotomy should not usually exceed 15 mm. A longer in-
cision entails the risk of retroduodenal perforation and bleeding. The retroduodenal artery is close to the posterior wall of the
duodenum across the distal common bile duct.
The Erlanger papillotome has become accepted as a standard instrument for endoscopic papillotomy. Modifications, such as
the “precut” papillotome or the papillotome clips with a guide
wire can be used for a narrow papillary ostium (Fig. 5.4.1).
Incision with Electrocautery
Use monopolar electrocautery with cutting and coagulation
currents in a blending ratio of 2:1. The choice of intensity depends on the output current of the unit being used. The coagulation current is intended to prevent bleeding and must not
cause severe edema when cutting since this increases the risk of
acute pancreatitis.
Standard Procedure (Erlanger Method)
Alternate Techniques for Difficult Situations
In the presence of a narrow papillary nipple pore that cannot be
probed with the Erlanger papillotome, one of the following
techniques may be used (Fig. 5.4.3). These techniques are not al-
ways easy to perform. They require sufficient experience and
routine.
Mechanical Lithotripsy
Mechanical lithotripsy of large non-extractable stones may be
performed endoscopically (Fig. 5.4.6a, b). Larger metal probes
may be used if an endoscope is not used. This technique has the
advantage of permitting application of greater force while pro-
tecting the fiber optic instruments.
Placement of the Nasobiliary Tube
The nasogastric-duodenal bile duct tube (see Fig. 5.4.7) is used
for irrigation and infusion of medication and contrast material.
Its main indications include purulent cholangitis, chemical
lithotripsy, and extracorporeal shock-wave lithotripsy (ESWL).
Fig. 5.4.1 Selection of papillotomes.
1 The Erlanger model (standard instrument)
2 “Precut” papillotome with short tip
3 “Long-nose” papillotome
4 Papillotome with guide wire
5 Needle papillotome
Complications
A stone impacted in the papilla can be accompanied by acute
pancreatitis, jaundice, and cholangitis. The dramatic syndrome
of biliary pancreatitis is often characterized by cholangitis and
cholangiosepsis. Endoscopic treatment is simple and provides
immediate relief.
Specific complications are primarily attributable to the papillotomy technique. These include:
쐌 Acute pancreatitis. This generally occurs as a result of dam-
age to the pancreatic duct during catheterization or is due to
an incorrect incision.
쐌 Retroduodenal perforation. The most common cause is an
excessively long incision.
쐌 Bleeding from the edges of the incision will usually stop
spontaneously. Severe bleeding often involves the retroduodenal artery. Practically such bleeding occurs only with
excessively long incisions.
Corrective Action
Acute pancreatitis: Nonoperative treatment is preferable. The familiar, established surgical principles apply to severe cases with
peritoneal reaction and systemic symptoms and signs.
Retroduodenal perforation: Drainage by nasobiliary and nasogastric tubes or temporary biliary stent and PEG, parenteral feeding, and antibiotics. Laparotomy is indicated in the presence of
peritonitis.
137