Indications and surgical preparation
Biliary tract surgery requires strict indications and careful preparation. Choledochotomy is performed when it is necessary to restore normal bile flow or decontaminate the biliary tract from pathological contents.
The main indications for the procedure include:
- Presence of calculi (stones) in the lumen of the bile ducts obstructing the outflow.
- Cicatricial narrowing, or strictures, of the common bile duct.
- Development of purulent cholangitis requiring immediate decompression and sanitation.
- Detection of parasitic infestation directly within the bile ducts.
The surgery is performed exclusively under endotracheal anesthesia, ensuring reliable pain control and respiratory management. The patient is placed on the operating table in the supine position. An important nuance is the patient's positioning: a roll must be placed under the lower part of the thorax. This elevated position significantly improves the surgical view. Access to the surgical field is completely analogous to that used in classic cholecystectomy.
Locating and opening the duct
The first and one of the most critical steps is locating the common bile duct. Anatomically, it is localized within the thickness of the hepatoduodenal ligament. For its precise identification, the surgeon uses a comprehensive approach: careful palpation of the ligament structures, gentle preparation of surrounding tissues, and, if confirmation is needed, a trial puncture.
Once the duct is identified, the surgical field must be securely isolated with gauze sponges. This is done to prevent infected bile or purulent contents from entering the free abdominal cavity.
The technique of opening the duct requires jeweler-like precision:
- Two silk traction sutures are placed on the anterior wall of the duct. They allow secure fixation of the wall and prevent it from slipping deep into the wound.
- A careful longitudinal incision is made between the placed traction sutures.
- The length of the incision must be strictly 1–2 cm.
- The location of the incision is of fundamental importance: it is performed precisely 1 cm distal to the insertion of the cystic duct.
Revision and patency test
Once the lumen of the common bile duct is opened, the surgeon proceeds to perform the main manipulations. At this stage, detected stones are removed, parasites are extracted, and a thorough visual and instrumental revision of the internal walls is performed.
A critically important stage of the operation is testing the patency of the biliary tract. If even a small obstruction is missed, the surgical intervention will be ineffective, and a reoperation will be required.
To objectively assess patency, two main methods are used:
- Mechanical probing. A special probe with a bulbous tip is introduced into the lumen. The surgeon carefully advances it both proximally (toward the hepatic ducts) and distally (toward the duodenum), assessing for any obstructions.
- Radiological control. Intraoperative cholangiography is performed. This method visualizes the entire ductal system using a contrast agent directly on the operating table and ensures the absence of residual (left-behind) stones or strictures.
Completion of surgery
The choice of the method to complete the choledochotomy directly depends on the clinical picture, the presence of inflammation, and the surgeon's confidence in the cleanliness of the bile ducts.
| Method of completion | Technical features and conditions of use |
|---|---|
| External drainage | Used in the vast majority of cases. Vishnevsky drainage or a T-tube (Kehr drain) is utilized. The incision on the duct is sutured with interrupted catgut stitches proximal to the placed drain. The drain itself must be fixed with a catgut ligature to the hepatoduodenal ligament to prevent displacement. |
| Primary closure | Applied to the duct without leaving an external drain. This option is permissible only under ideal conditions: complete absence of signs of infection (purulent cholangitis) and one hundred percent confidence in the absolute patency of the duct according to probing and cholangiography data. |
Briefly: answers to topical questions
What special surgical instruments are used to extract calculi from the lumen of the common bile duct?
Forceps are used to extract calculi from the bile ducts; this technique is called lithoextraction. To detect impacted or floating stones, the duodenum is mobilized using Kocher's maneuver and the papilla is palpated over a probe. The patency of the major duodenal papilla is checked with a 3–4 mm probe, and the patency of the ducts is checked with a bulbous probe proximally and distally.
Which specific surgical access (eponym or name) is used to perform a choledochotomy?
Surgical accesses similar to those used in cholecystectomy are employed for choledochotomy. The following open approaches are used:
- Right subcostal oblique incisions — Kocher or Fedorov incision;
- Upper midline approach;
- Bilateral subcostal approach.
Additionally, the procedure can be performed using laparoscopic access (laparoscopic choledochotomy).
Which anatomical structures, besides the bile duct, run within the thickness of the hepatoduodenal ligament?
In addition to the common bile duct, the following anatomical structures pass within the thickness of the hepatoduodenal ligament (lig. hepatoduodenale):
- Proper hepatic artery (a. hepatica propria) — located on the left, includes right and left branches;
- Portal vein (v. portae) — situated between the artery and the duct posteriorly;
- Common hepatic and cystic ducts (ductus hepaticus communis, ductus cysticus) — form the common bile duct on the right;
- Right gastric vessels (a. et v. gastricae dextrae) — lie in the lower section;
- Gastroduodenal vessels (a. et v. gastroduodenales);
- Lymph nodes and vessels;
- Hepatic plexus (plexus hepaticus) includes the anterior and posterior plexuses.
To remember the strict conditions for performing a primary closure of the duct, use the "Two P's" rule: Patency (complete) and Presence of no infection (complete absence of infection). If even one "P" is missing, placement of a drain is mandatory.
Class and exam questions
Where exactly is the incision made on the duct?
A longitudinal incision 1–2 cm long is made on the anterior wall of the common bile duct, exactly 1 cm distal to the insertion of the cystic duct.
How to ensure that the duct is clear after stone removal?
For this purpose, a bulbous probe is used, passing it in the proximal and distal directions, and intraoperative cholangiography is mandatory.
Which structures are used as landmarks to locate the common bile duct?
The duct is localized within the thickness of the hepatoduodenal ligament. For its precise identification, palpation, tissue dissection, and trial puncture are used.
Can the duct be closed primarily without drainage?
Yes, but this is permissible exclusively when there is absolute confidence in the complete patency of the biliary tract and a total absence of signs of an infectious process.
What else to study on this topic
- Topographic anatomy of the hepatoduodenal ligament.
- Technique of surgical access in cholecystectomy.
- Features and differences of Vishnevsky and Kehr (T-tube) drains.
- Methodology of intraoperative cholangiography.
- Properties of catgut and types of sutures used in biliary surgery.
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