A pursestring suture is placed on the fundus of the gallbladder in the center of which the gallbladder is punctured with a Trocar and the thick gelatinous contents removed by electric suction. Some 60 to 80 ml of radiopaque substance are then injected through the puncture site.
The pursestring suture is tied, leaving the ends long co apply traction to the fundus of the gallbladder upward and to the right so that the shadow of the gallbladder will not become superimposed on the shadow of the common bile duct.
SPHINCTEROTOMY AND SPHINCTEROPLASTY
The term sphincterotomy of the sphincter of Oddi, or simply sphinctcrotomy means transcction of the muscular fibers of said sphincter, Sphincteroplasty is complementary to sphincterotomy, consisting of suturing the choledochal mucosa to the duodenal mucosa. The great majority of surgeons advise the addition of sphincteropiasty in all cases.
At present sphincterotomy is very frequently done by the endoscopic route and is not accompanied by sphincteroplasry. It is, however, associated with good imrnediarc and late results. Organic stenosis of the sphincter of Oddi is the principal indication for sphincterotomy and sphincteroplasty.
This condition is, however, infrequently observed. Sphincterotomy of the sphincter of Oddi used to be carried out in many surgical centers in patients with biliary calculi without clear documentation of its need. At present surgical sphincterotomy is performed, in the great majority of cases, to remove calculi that are impacted in the papillary or to facilitate postoperative passage into the duodenum of calculi that are lodged in the biliary ducts.
Endoscopic sphincterotomy is usually performed to remove a calculus that is impacted in the papilla, to remove calculi from the biliary duct using a Dormia basket, or to facilitate passage of calculi into the duodenum. We will now describe the technique used in sphincterotomy and sphincteroplasty as perfor:ncd surgically through the transduodenal approach.
Exploration of the Common Bile Duct by Palpation
A superficial palpation of the common bile duct is usually performed when the abdomen is open in a dure for biliary lithiasis. To perform an adequate palpation of the common bile. duct and neighboring organs such as the pancreas and duodenum, il is neeessary to perform a Vautrin Kocher maneuver. This maneuver should be performed if the operattve cholangiogram shows the presence of any pathology.
On the contrary if the cholangiogram reveals that the common bile duct is normal in caliber without abnormal images of calculi and the dye passes readily into the duodemun it is not necessary to perform the Vautrin Kocher maneuver.