Surgery on the biliary ducts and Ampulla of Vater

Surgical interventions on the bile ducts

Operative surgery of the extrahepatic bile ducts includes several basic approaches. The choice of a specific method depends on the clinical presentation and the degree of obstruction. There are four main groups of surgical procedures:

1. Opening of the duct lumen (cholangiotomia). This intervention is performed for exploration, removal of calculi, or elimination of other obstacles. Cholangiotomy can be completed in two ways: by primary closure of the duct wall or by placing a special drainage tube for temporary bile diversion.
2. Creation of biliodigestive anastomoses. If natural passage cannot be restored, the surgeon creates a bypass. The common bile duct can be anastomosed to the duodenum (choledochoduodenoanastomosis) or to a loop of the jejunum (choledochojejunoanastomosis).
3. Resection of the bile duct. Involves complete surgical excision of the pathologically altered segment.
4. Reconstructive operations. Complex plastic procedures aimed at restoring the normal anatomy of the biliary tract.

Procedures on the major duodenal papilla (MDP)

The major duodenal papilla (MDP) is a key anatomical structure through which bile enters the intestine. Surgical interventions on the MDP are very often combined with parallel operations on the gallbladder and proximal ducts.

Indications for surgical treatment:

• Complete or partial obstruction of the terminal parts of the common bile duct (choledochus).
• Cicatricial stenosis or a tumor process within the papilla itself.
• Various pancreatic diseases that lead to mechanical compression of the duct orifice from the outside.

Main types of operations:

• Papillosphincterotomy. The essence of the method is the careful dissection of the muscle fibers of the MDP ampulla sphincter. This allows widening the orifice and eliminating the obstruction.
• Transduodenal choledochoduodenostomy. A more complex intervention in which an internal anastomosis is formed directly between the common bile duct and the duodenal lumen. The main purpose of this procedure is the reliable removal of impacted calculi from the orifice and ensuring adequate bile outflow into the digestive tract.

Surgical correction in portal hypertension: omentopexy

In portal hypertension syndrome, the surgeon's main task is to create pathways for blood outflow. Portacaval vascular anastomoses are used for this purpose. However, any such operation must necessarily be supplemented by omentopexy.

Essence and purpose of omentopexy: The technique involves suturing and securely fixing the greater omentum to various organs (e.g., omentohepatodiaphragmopexy or omentorenopexy). The main purpose of this step is to stimulate the development of new vascular collaterals that help decompress the portal system. A crucial condition for performance is that the omentum must be completely unaffected by pathological processes and have sufficient dimensions.

Plastic closure technique: During the operation, the omental flap is divided into two parts. Further fixation of the flap follows strict rules:

• The right part of the flap is always sutured directly to the liver.
• The left part is fixed to the anterior abdominal wall.

An alternative technique also exists: the right part of the flap is tightly wrapped around the inferior vena cava and a pre-decapsulated kidney, while the left part is sutured to the liver tissue.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Technique of creating portacaval vascular anastomoses.
• Surgical interventions on the gallbladder.
• Topographic anatomy of the terminal part of the choledochus.
• Omentohepatodiaphragmopexy and omentorenopexy: detailed analysis.

Other topics in the "Abdominal Surgery" section

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