Stone extraction via the T-tube 89 3. Endoscopic method 89 4. Preparation for stone extraction 90 5. Technique 90 6. Results 91 7. Complications 91 8. Discussion 91 Index of Subjects 99 CHAPTER 1 INTRODUCTION This book was conceived as a descriptive atlas of most reliable indication for common bile duct ex routine biliary surgery i. e. , cholecystectomy and ploration. The cholangioscope allows a visual ex exploration of the common bile duct. For the pro ploration of the biliary tree and permits the re ject the two authors worked together for one week moval of common bile duct calculi and other as biopsy under direct visual con at Ninewells Hospital and Medical School, Dundee procedures such on a series of patients with biliary tract disease trol. Both procedures have been described in detail especially selected for the exercise. With the con with emphasis on the practical aspects of their use. sent of the Tayside Health Board and the patients The era of blind bilary surgery is over and the concerned, all the operations and peri-operative sooner this message is received by all concerned, procedures were filmed by the photographic mem the better the outcome of biliary surgical practice bers of the team, Mr. and Mrs. Paz-Partlow. Ad overall. ditional case material has been obtained from It has not been our intention to produce a com Cedars Sinai Medical Center, Los Angeles.

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Introduction.- 2. Review of existing problems in biliary tract surgery.- 3. Surgical approach and principles.- 1. Introduction.- 2. Prophylactic measures.- 2.1. Infectious complications.- 2.2. Haemorrhagic complications.- 2.3. Renal failure.- 3. Pre-operative biliary decompression in the jaundiced patient.- 4. Operative principles.- 4.1. Surgical access.- 4.2. Patient positioning.- 4.3. Appropriate incision.- 4.4. Illumination of the operating field.- 4.5. Packing.- 4.6. Exposure of relevant anatomy.- 5. Drainage of the supracolic compartment after biliary operations.- 4. Operative cholangiography (in cooperation with J.A. Hamlin and M. Paz-Partlow).- 1. Introduction.- 2. Common bile duct explorations.- 3. Unsuspected stones.- 4. Cannulation techniques.- 5. Initial and/or completion cholangiograms.- 6. Standard technique.- 6.1. Technique and equipment.- 6.2. Patient's positioning.- 6.3. Scout film.- 6.4. Injected volume.- 6.5. Contrast material.- 6.6. Coordination of exposure.- 6.7. Mobile C-arm fluoroscope.- 7. Fluoro-cholangiography.- 7.1. Easy positioning of the patient.- 7.2. Optimal beam collimation.- 7.3. Shorter exposure time.- 7.4. Automatic exposure control.- 7.5. Minimal technician activity.- 7.6. Control of the exposure sequence.- 7.7. Serial films.- 7.8. Decreased examination time.- 7.9. Indirect radiography.- 8. Anomalies of surgical importance.- 8.1. Short cystic duct.- 8.2. Drainage of cystic duct in the right hepatic duct.- 8.3. Aberrant ducts.- 8.4. Ductal diverticula and choledochocele.- 8.5. The acute or emergency case.- 9. General aspects.- 10. Radiation protection.- 11. The cystic duct.- 12. Cholecysto-cholangiogram.- 13. The choledocho-cholangiogram.- 13.1. Direct needle puncture.- 13.2. Butterfly needle puncture.- 13.3. Special needle clamp.- 13.4. T-tube insertion.- 14. Contact selective cholangiography.- 15. Reason for failure for operative cholangiography.- 15.1. Overfilled ducts.- 15.2. Underfilled ducts.- 15.3. Poor quality films.- 15.4. Improper positioning.- 15.5. Obscured field.- 16. Artifacts.- 17. Complications of operative cholangiography.- 18. Reformed calculi.- 19. Complications of T-tube removal in the post-operative period.- 20. Results of operative cholangiography.- 20.1. Advantages.- 20.2. Disadvantages.- 5. Operative biliary endoscopy (cholangioscopy) (in cooperation with M. Paz-Partlow).- 1. Introduction.- 2. Instrumentation.- 2.1. Accessories.- 3. Technique.- 3.1. Mobilization of the duodenum.- 3.2. Endoscopic appearance.- 3.3. The cystic stump remnant.- 4. Endoscopic anatomy and pathology.- 4.1. Normal findings.- 4.2. Cholangitis.- 4.3. Calculi.- 4.4. Ampullary stenosis.- 4.5. Neoplasms.- 4.6. Miscellaneous.- 5. Repeated cholangioscopy.- 6. Complications.- 7. General aspects.- 7.1. Sterilization.- 7.2. Maintenance.- 8. Evaluation of results.- 9. Conclusions.- 6. Biliary manometry and debimetry.- 1. Introduction.- 2. Usage.- 3. Pharmacolgy of the sphincter of Oddi (SO).- 3.1. Effect of hormones and peptides.- 3.2. Effect of pharmacological agents.- 4. Biliary pressure indices.- 4.1. Resting (initial, interdigestive) pressure.- 4.2. Passage (yield, opening) pressure.- 4.3. Filling pressure curves.- 4.4. Residual pressure.- 4.5. Flow rate (debimetry).- 4.6. Incremental pressure and recovery time.- 5. Dynamic (transducer) manometry.- 5.1. Endoscopic sphincter zone activity.- 5.2. Technique of operative biliary manometry.- 6. Disorders of the sphincter of Oddi.- 6.1. Iatrogenic stricture.- 6.2. Papillitis/Oedema.- 6.3. Papillary stenosis (choledocho-duodenal junctional stenosis).- 6.4. Functional disorders.- 7. Exploration of the common bile duct.- 1. Introduction.- 2. Technique of CBD exploration.- 2.1. Mobilization of duodenum and head of pancreas.- 2.2. Exposure of the CBD.- 2.3. Choledochotomy.- 2.4. Cholangioscopy.- 2.5. Additional procedures.- 2.6. Insertion of T-tube.- 2.7. Closure of choledochotomy wound.- 3. Trans-duodenal exploration od CBD.- 4. Intra-hepatic calculi.- 5. Assessment of terminal end of the CBD and sphincteric region.- 6. Post-operative removal of T-tube.- 7. Conclusion.- 8. Postoperative removal of retained stones through the T-Tube tract (in cooperation with J.A. Hamlin).- 1. Introduction.- 2. Stone extraction via the T-tube.- 3. Endoscopic method.- 4. Preparation for stone extraction.- 5. Technique.- 6. Results.- 7. Complications.- 8. Discussion.- Index of Subjects.