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Atlas of surgery volume i

)f I


Gallbladder and Biliary Tract
Cbolecystectomy :1
Common Duct Exploration


Sph inctcroplasty, Including T ransampullary Common Duct Exploration


Side-to-Side Choledochociuodeno'lomy 28
Resection of a Benign Bile Duct Stricture Wit h iStcnts a nd Hepa ticojejunos tomy 38

Resec tion of a Prox imal Cholangiocarcinoma With Reconstruct ion Utilizing Silastic Transhepatic
Biliary Stents an d Bilateral Hepaticojejunostom ics 58

Resection of a Proximal ChoiangiocarcinolllCl With Hepa tic Lobectomy and Recon st ruction l :tiiizinga

Silastic Transhepat ic Biliary Stent and Hepat icojejullostomy


Prox imal Choiangiocarcinorn a: Palliation by Tran shepat ic Stcnting and Hepaticojejunostomy
I~ esection of Hepatic Duct Bifurcat ion. Dilatation of In trahepatic Biliary Tree. and Prolonged
Stenling With Transhepatic Bil iary Stents for Sclerosing Cholangitis 94
Hepaticojej unostomy for Distal St ri cturing Seconda ry to Sclerosing Cholangitis lOll
Resect ion 01 Choledochal Cyst 116
Transhepat ic Slenling for Caroli 's Disease' l28
Wedge Resection of Liver and Regional Lymph Node Dissection for Carcinoma of the
Gallbladder I-U

The Liver
Anatomy of the Li\'er


:\onanatomical Liver Resect ions 156
Resection of Lateral Segment of Left Lobe of Liver 162
Resection 01 Left Lobe QI Lil'er J(jll
Resection of Right Lube of Li\'er 178
Resection 01 Right Lobe of Li\'er Plus \Iedial Segment 01 Left Lobe ITrisegmentectomy I
Insertion of Infusaid Pump for Hepat ic Artery Inlusion 20()
Resection of Simple C\,st of Lilw 206
\Ianagement 01 Hydatid Cyst Disease of Liwr 1](1
Draina~ ... f Li\"~;!" .-\b5('e3ses :!2.J



Portasyste mic Shu nts
Interposition Mesocaval Shunt 252
Distal Splenore nal Shunt 2 66
Portacaval Shunt 274
End·to·Side 276

Side·to·S ide 282
Interpos ition " H" Graft 286
Direct Mesocava l Shunt 288
Mesoa trial Shunt 2 98
Le Veen Shunt 312

The Pancreas
Longitud inal Pancreat icojejullostomy: PueslOw Procedure 326
End·to·End Pancreaticojejunostorny: DuVal Procedure 342
Distal Pancreatectomy fo r Chro nic Pancreatitis 350

Ninet y-Fi ve Percent Dista l Pancreatectomy for Chronic Pancreatitis 362
Duct Papillolom y for Pancreas Divisum 366
Drainage of Panc reatic Pseudocyst into Roux·en·Y Jejunal Loop 370
Drainage of Pancreatic Pseudocysl into the Stomach 380
Drainage of Pancreatic Pseudocyst into the Duodenum 384
Pancreaticoduoden ectorny (Pylorus· Preserving Whipple Procedure) 386
Palliative Bypasses for Un resectable Periampullary Cancer 414
Distal Pancreatectomy for Tumor 428
Laparotomy for Insulinoma 436

Drainage of a Pancreatic Abscess 442
Diverricularizat ion of the Duodenum and Pancreatic Drainage for Combined DuOOer..a1 and Pancrr
Trauma 454
Pyloric Exclusion and Pancreatic Drainage for Combined Duodenal and Pancreatic Trauma ~

Gallbladder and Biliary Tract

...... - ....'~ --''''''''''

Operative Indications
atients with symptomatic gallstones are candidates for
cholecystectomy. In the past even patients with asymptomatic
gallstones were thought to require cholecystectomy. Howe\'<7,
recent natural history data suggest that unless patients with
gallstones have symptoms referable to their biliary tract, the likeljbrxxJ
developing significant morbidity is low enough to justify merely t
patient and performing cholecystectomy only if symptom arise. There::JaY be
exceptions to this rule. An individual living in or traveli ng to remorearea"
where medical care is not readily available may be a candidate for prophylactic
cholecystectomy if stones are present. Other factors such a diabe or other
systemic illnesses may also modify this decision. Most patients wilh
asymptomatic gallstones, however, are no longer considered candida
Some patients with symptomatic gallstone disease may be man
extracorporeal shock wave lithotripsy. At present, however, thi represents only
a minority of patients with symptomatic gallstones; the majority are managed
by cholecystectomy. There are also other rare indications for cho ecystectomy.
other than symptomatic calculus disease. Individuals who are ha";';"""=
Infusaid pump inserted for the management of colorectal meta
(0 the IDW
routinely undergo cholecystectomy. In addition, patient undergoir: palliative
transhepatic stenting of their biliary tree at the time of urgery
undergo cholecystectomy because of the risk of subsequent cho eqs - -


Operative Technique
holecystectomy can be performed through a right ubcos . upper
midline, or right paramedian incision. The right ubcos incision is
preferred. Once the abdomen is entered, the peritoneal ca -',- '"
explored for evidence of other pathology. When none'
. the
surgeon proceeds with the cholecystectomy. Exposure i greatly facilitated if an
upper hand retractor is used to retract the skin, subcutaneous tissues. and
costal margin. A Deaver retractor then easily exposes the under"'<;'"
liver (A).


Hepatic flexure of colon


he hepatic flexu re of the colon is retracted in a caudal di rection,
frequently with a Mi kulicz pad , and the stomach is packed medially,
also with a Mikulicz pad. A clamp is placed on the fund us of the
gallbladder, and it is gen tly retracted in a cephalad direction. Thesero a
overl ying the porta hepatis is opened and the portal struct ures identified (B).
The cystic duct is identified and looped with a vessel loop. If it is doubly
looped, this will prevent gallbladder stones from passing through the cystic duct
into the common duct du ring gallbladder manipulation (C).
Dissection of Calot's triangle allows identification of the cystic artery,
which arises from the common hepatic or right hepatic artery. This anatom y is
extremely variable, and this area has to be dissected carefully and completely to
clearly identify the cystic duct and cystic artery and to avoid injuring
anomalous structures. The right hepatic artery freq uently fo llows the cystic
duct and/ or gallbladder very closely before cu rving back up into liver
parenchyma, and for a 1· or 2·cm course it can easily be confused with the
cystic artery. The arterial anatomy has to be dissected such that the cystic
artery is clearly seen joining the gallbladder before one can be certain of its
identification. Likewise the cystic duct, which usuall y arises from the common
hepatic duct, may arise from the righ t hepatic duct or from one of the two
segmental ducts to the right lobe of the liver. This area has to be carefull y and
completely dissected to be certain of the anatomy.
If the anatomy cannot be clearly delineated, one shou ld stop further
dissection in th is area and proceed to mobilize the gallbladder from above
downward. When the gallbladder has been mobilized out of the liver bed, the
anatomy of this area will become clear. Early cholangiography, performed by
injecting contrast directly into the gall bladder or ductal system, may also be
hel pful.


he:Jabc a

Cystic duct

Cystic a.
and duct

transverse abdominal incision is made in the anterior axillary line,
approximately 2 inches below the costal margin. In a particularly
cachectic individual with no subcutaneous tissues, the valve may be
inserted in the rectus sheath and covered by the rectus muscle. In
most instances, however, the valve is inserted lateral to the rectus sheath.
The transverse incision in the right axillary line is deepened down to the
external oblique muscles, which are spread in the direction of their fibers (C).
The internal oblique muscles are then separated in the direction of their
fibers (D), and the transversus abdominis muscle fibers on the peritoneum
exposed. In preparation for passing the tubing from the valve, in a cephalad
direction, a small opening is made through the abdominal wall muscle layers
into the subcutaneous space (D).




_ _ __ __


R hepabc a

_ _ ___ Cyshc duct

Cysbc a

Cystic a. and duct



- - - --J

nee [he gallbladder has
mobiJim:I out of the liver
bed, [he anatomy i generally dear, and if the cystic artery has not
been previou ly identified, control of that vessel can now be
accomplished. Controversy remain as to whether or not routine
cholangiography should be performed. Our bia i that selection hould be used
and that not all patients need undergo operative cholangiography. If one is
operating upon a patient with normal liver funct ion tests and a single, large
cholesterol gallstone, the likeli hood of common duct stones is so Iowa to be
negligible, and operat ive cholangiography is unnecessary. In a significant
proportion of patients undergoing cholecystectomy, however, uperative
cholangiography will be required.
After placing a tie proximally at the cystic duct-gall bladder junction, a
small opening is made distally in the cystic duct and a cholangiocatheter
inserted (H). The cholangiocatheter is secured with a 2-0 silk that i tied around
the dista l cystic duct containing the catheter and then passed through the
opening on the catheter.
After adequate cholangiography has been obtained, the cholangiocatheter is
removed, the cystic duct is doubly clamped and divided, and the gallbladder is
removed from the operative field (1).
The cystic duct stump is then ligated with a 2-0 silk (J ). Many urgeons
contin ue to use sil k, as we do; others are concerned abou t it acting a a nidus
for gallstone form ation and thus use a synthetic absorbable material.
The right upper quadrant is copiously irrigated with an an tibiotic
containi ng saline solution. Hemostas is in the bed of the li ver is achieved with
the electrocautery.
Whether or not to drain the liver bed and porta hepatis following routine
cholecystectomy rema ins somewhat con troversial (K). There are virtually no
significant liabilities from drain ing the operative site following elective
cholecystectomy, but many studies have shown it to be unnecessary. The only
reason for leaving a drain behind is if an unexpected bile leak occur from a
small , unrecognized bile ductule in the bed of the li ver; leaving drain in place
obviates the need for reexploration. If drains have not been placed, this can
present a serious life-th reatening complication. Even though rare, it seems to us
that the discomfo rt of a dra in is worth the avoidance of this unusual but lifethreatening complication. We prefer a closed suction drain left in place for
hours. If biliary drainage does not occu r, the drain is removed ju t prior to



Cystic duct ---~~tiI'


-·adder fossa - --

- - -- - ----Jr-'ir.

Cystic a. and
duct stumps ----,~'7"

Common Duct Exploration
Operative Indications
ost common duct explorations for calculi are performed in
conjunction with cholecystectomy. In the past, patients who bad
previously undergone cholecystectomy and presented with primary
or recurrent common duct stones were also treated surgically_
Now the majority of such patients can be managed non operatively with
endoscopic papillotomy. Thus today the only patients with common duct caIaili
who routinely are treated surgically are those patien ts with a gallbladder in
place who also require cholecystectomy.
The most common indication for common duct exploration today i the
radiographic demonstration of stones in the biliary tree. T he majority of
patients in our institution who present with jaundice have their biliary tree
anatomy and pathology delineated cholangiographically prior to surgery. This is
carried out preoperatively via either endoscopic or percutaneous tran hepatic
cholangiography. However, in the event that cholangiography has not been
performed preoperatively, operative cholangiography is performed at the timed
surgery in most patients who prove to have biliary tract stones. Common dud
exploration in the absence of preoperative or intraoperative cholangiography is
infrequent in our institution. At the time of elective cholecystectomy, if a tone
is unexpectedly palpated in the biliary tree or a dilated com mon duct is
unexpectedly found, the patient would undergo operative cholangiography to
demonstra te the entire biliary tree prior to common duct exploration.


Operative Technique
nce the decision is made to perform a com mon duct exploration. the
duoden um is kocheri zed extensively (A). This allows one to palpate
the distal common duct as it traverses behind the first portion of the
duodenu m and head of the pancreas, prior to entering the di tal
second portion of the duodenum through the am pulla. It is impossible to
adequately palpate this portion of the biliary tree without extensive
kocherization. The common duct is cleaned fo r a 2· or 3·cm length, generaUy
between the cystic duct stump and the duodenum .
tay sutures of 5-0 synthetic nonabsorbable material are placed in the
common duct, and a choledochotomy is performed (B). The choledochotomy
hould be of ample length, at least 1 em, to allow ea y in trumentation of the
duct without traumatic exten ion.
lOnes are often pontaneou Iy evacuated a bile i ues forth from the
common duct opening. At the same time any tones that are palpated in the
distal common duct can be milked up toward the choledochotomy and reIIIO'13I



, ___:;:?'- - - - - Cystic

a and duct slumps

-'.C±,C- ----,----- - -- - Common duct

Cystic a.



Common duct stone


here are a variety of instruments that one can utilize to explore the
biliary tree; generally we utilize all of these instruments in an effort
to completely rid the tree of biliary calculi. It is important that the
choledochotomy be made adequate in length, so that the instrument
used to extract biliary calculi do not traumaticall y extend the incision.
A variety of scoops with malleable handles can be used to pass distally
down to the ampulla and up into the intrahepatic biliary tree via both the right
and left hepatic ducts (D). These scoops come in a variety of sizes and can be
extremely effective in removing small stones or biliary sludge.
Randall Stone forceps are also utilized, and many surgeons use these
instruments initially in the duct exploration (E). These forceps come with a
variety of curves that range from almost straight, as pictured here, to righ tangled and even acute-angled. These instruments are very effective in grasping
larger, well-formed stones.
The biliary balloon catheter is particularly usefu l; it can be passed down
distally, through the ampulla, and then inflated to document patency of the
distal biliary tree into the duodenum. This is perhaps the safest way to
demonstrate an open ampulla. In using the balloon catheter, one has to be
careful that it is not overdistended. Experimental studies have demonstra ted
intrahepatic ductal disruptions and liver abscesses formed from overinflation of
the balloon. If one constantly moves the catheter to and fro as the balloon is
inflated, being certain that the balloon catheter remains mobile within the
ductal system, overinflation is unli kely. T he balloon catheter is particularly
effective in retri.eving intrahepatic stones (F).



Inlrahepa 'c

'---_ _

Small stones
and sludge



catheter - -- - . .- 4


ne of the most effective maneuvers in ridding the biliary tree of
stones and biliary sludge is irrigation using a small French cath
A #12 French catheter placed intrahepatically into the right and I
hepatic ducts, together with large volume irrigation with saline, is
extremely effective in ridding the entire intrahepatic biliary tree of mall st
(G). This maneuver can also be carried out distally.
Passage of the French catheter through the ampulla into the duodenum is a
safe way of demonstrating ampulla patency (H).
The use of Bakes dilators is controversial. Many surgeons feel that the
potential for creating false passages, injuring the ampulla, and/or initiating
postoperative pancreatitis is so great that these metal dilators should never be
used. Other surgeons feel it is acceptable to carefully and gently utilize the
smallest Bakes dilator to demonstrate patency of the am pulla only (and not for
dilatation). Our philosophy is that it is safer to demonstrate patency of the
ampulla with either a balloon catheter or a small French catheter. Ii neither of
these is effective in demonstrating patency of the ampulla, then very cautious
and gentle use of a small Bakes dilator is acceptable. Generally the Bake dilator
easily passes gently through the ampulla, and patency can be demonstrated by
seeing the "steel gray" end of the dilator pressed against the lateral wall of the
duodenum (1). We feel there is rarely an indication for the use of a Bak dilator
larger than a #3.


Irriga 'on



Catheter tip
.a_--'-'_ _ _ _ through
ampull a





any biliary tract surgeons have adopted the routine use of
choledochoscopy during common duct exploration. T hi can be
carried out with either a rigid right·angled scope or a flexible
fiberoptic instrument. Many studies demonstrate that operative
choledochoscopy significantly lowers the incidence of retained common duct
stones. The rigid scope is easier to use but allows one to visualize a relatively
smaller proportion of the intrahepatic and extrahepatic biliary tree (J).
The flexible scope is more difficult to use, but it allows the surgeon to
visualize a greater extent of the intra· and extrahepatic biliary tree (K).
With either instrument one can utilize balloon and basket catheters to
remove stones visualized in the biliary tree (insets).
Following completion of the common duct exploration, a T-tube should be
inserted routinely. Our preference is for the variety of T - tube with a larger
diameter external limb and a smaller diameter T. We further decrease the size
of the T by cutting off the back wall. A wedge should also be removed from the
back wall to allow collapse of the two T - limbs when the T -tube is removed (L
Following insertion of the T -tube, the choledochotomy is closed with a
continuous suture. Many surgeons feel that synthetic absorbable material,
either 4-0 or 5-0, should be utilized to eliminate the theoretical possibility of a
permanent suture material acting as a nidus for stone formation. Other,
however, have utilized silk, or even synthetic nonabsorbable material, without
any obvious adverse effects.
The T -tube should be brought straight out laterally, without sharp turns
to allow for easy instrumentation s ubsequently if a retained stone should be
identified (M).
Closing cholangiography should always be performed. If filling defect
suggestive of stones are seen, the duct exploration should be repeated. Except in
emergency situations, the surgeon should not rely upon postoperative mean of
stone extraction to substitute for a completely successful operative procedure. If
contrast does not enter the duodenum, glucagon should be administered. If
repeat cholangiography still does not demonstrate contrast in the duodenum,
the surgeon should consider opening the duodenum and performing a
sphincteroplasty (demonstra ted on pages 18-27) to be certain there is not a
ampullary stone. The area of the choledochotomy is drained with Penrose or
closed suction drains.



;.-_ _ _ choledochoscope

f-_ _ _


0;--;.-----_ _ _ _ _ _


Sphincteroplasty, Including
Transampullary Common Duct
Operative Indications
phincteroplasty is an operative procedure that has been used in a
variety of settings over the past several decades. For many years it was
utilized as treatment for recurrent acute and/or chronic pancreatitis.
This is now considered only a rare indication in an unusual instance
where the pancreatitis appears to emanate from a proximal pancreatic duct
structure. 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. Recently there has
been some enthusiasm for sphincteroplasty and septotomy of the pancreatic
duct orifice for the management of patients with refractory postcholecystectomy
abdominal pain, perhaps secondary to stenosis of the pancreatic ductal orifice.
Sphincteroplasty has also been utilized for calculus disease of the biliary
tract. If after a common duct exploration the surgeon is not certain that all of
the stones have been removed, some surgeons have s uggested opening the
duodenum and performing a sphincteroplasty so that any retained stones may
pass spontaneously. It is still used frequ ently for patients who have an impacted
distal common duct stone that cannot be retrieved from above through a
choledochotomy. A sphincterotomy is performed to disimpact the stone, and
most s urgeons will proceed to extend to the incision and convert it in to a form al
sphincteroplasty. Man y biliary tract surgeons utilize sphincteroplasty if a
patient is treated operatively for a recurrent or primary common duct stone.
Most of these patients are now managed with endoscopic papillotomy. If tha t is
unsuccessful and the patient requires laparotomy, most biliary tract surgeons
now feel that it is impor tant to add a drainage procedure to common duct
exploration and stone extraction in many of these patients. Sphincteroplasty
can be successfully used as the drainage procedure.
Finally, we have utilized sphincteroplasty in recent years as a means of
exploring a common duct for calcu li when the common duct is of normal or
s mall caliber. Common duct exploration through a choledochotomy and
subsequent T - tube insertion carries sign ificant morbidity if the diameter of the
bile duct is small. Exploration through the ampulla is a good alternative. T he
operative procedures of sphincteroplasty and septotomy will be demonstrated,
as well as retrograde common duct exploration through the sphincteroplasty


Operative Technique


he abdomen i entered through a right ubcostal incision. If the
gallbladder i in place, a cholecystectomy i perlormed (see pages 2-9).
After the gallbladder has been mobilized, if operative cboIangiograpby
is required. It IS performed.




____ __ _~~~~

~~,--,--_ _---'

"---"-'=--';--_ _ _ Cystic

.:!l~~-=-,2_-____:;;_;_~_. Head of

inflated in


fte r the decision has been made to perform a sphincteropla ty, a small
opening is made in the cystic duct, and a balloon catheter i inserted
into the common duct, distally through the ampull a and into the
duodenum (A). The duodenum is then kocherized, and following
balloon inflation, the area of the ampull a can be identified by palpation. The
longitudinal duodenotomy is placed directly over the point where the urgoon
palpates the balloon .
After stay sutures of 3-0 silk are placed in the duodenum, the balloon
catheter is advanced beyond the ampulla so as not to perforate the balloon
the duodenotomy is performed (B).
The duodenotomy is performed with the electrocautery. After the
duodenotomy opening is made, by palpation the surgeon can identify the ballkx:lD
(C) and the location of the ampulla.



uu.ny _ _ _ _----;_

+ -,



nce the location of the ampulla has been identified, the
i extended. tay sutures of 5- 0 synthetic absorbable rna . 3!i
placed at 3 o'clock and 9 o'clock on the ampulla. Using the ba!lioor
catheter as a guide, a sphincterotomy is performed at 11 120'
with the electrocautery (D). The opening is made 3 or 4 mm at a .
Once the ampulla has been opened, the ductal mucosa i utum:l1D
duodenal mucosa with a series of interrupted 5- 0 synthetic absorbable~~A
(E). T hese sutures are gathered in hemostats; their retraction
exposure of the area (F).
After the initial sphincterotomy incision, the pancreatic orifice ,.".",identified with a silver probe (G). If one has difficulty in iden' .
pancreatic duct, secretin can be administered intravenou Iy.
T he sphincterotomy is extended, generally for 1 to 2 ern, wid! :un.=
synthetic absorbable sutures being placed to approximate duodeaal ~~ ...,.:.;o,~
mucosa. Finally an apex suture is placed when the diameter of the
sphincterotomy is deemed sufficient (G).
T he length of the sphincteroplasty incision will vary dependin''J .............
reason for its performance. If one is perform ing a sphincteropla ty IDf':rly
dislodge an impacted common duct stone, a larger incision i unnea:5Sthe sphincteroplasty incision is large enough to disimpact the lone.
other hand , if one is performing a sphincteroplasty incision in a ~.,.,..t~.n...
dilated duct because of the concern of leaving behind retained 10
sphincteroplasty incision 2 to 3 cm in length may be carried out. One
careful not to extend the sphincteroplasty incision beyond the point wt:e::i~Clf
biliary tract and duodenum have a common wall. With careful appn:lrimtDl,
however, of the ductal and duodenal mucosa, risk of retroperitoneal or
intraperitoneal leakage is virtually eli minated .
If the sphincteroplasty has been carried out for what are believed m
symptoms related to the pancreas, from a stenotic pancreatic duct
septotomy can be performed with Pott's scissors (H). This inci ion can C:'S~~
be extended for 4 or 5 mm, at which point the septum thicken a thethe pancreatic and biliary tree diverges. Some feel that the pancreatic and
ductal mucosa should also be approximated with 5- 0 or 6-0 ynthetic
absorbable material.



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