|
HOW I DO IT / HOW I DID IT SURGICAL PROCEDURES |
|
SPHINCTEROTOMY / SPHINCTEROPLASTY
§ Patient supine under SAB § Asepsis- Antisepsis § Sterile drapes placed § Right Kocher incision done on the skin carried and down to the subcutaneous tissue § Rectus sheath cut and opened § Rectus abdominal muscle divided with electrocautery § Posterior rectus sheath picked up and cut § Peritoneum identified cut and entered § Pass a hand over the right lobe of the liver and pulled it down § Palpated gallbladder, confirming the presence of stones § Intra op findings noted § Gallbladder is grasp with forceps and retracted laterally § Put a finger into the foramen of Winslow and palpate the common bile duct for stones and the head of the pancreas for any mass § Do an extensive Kocher Maneuver, continued up to the third portion of the duodenum almost as far as the point where the superior mesenteric vein crosses the anterior wall of the duodenum § Intraoperative cholangiogram done.
COMMON BILE DUCT EXPLORATION § Two fine silk 4-0 sutures are placed a few mm apart in its wall § The field entirely walled off with moist gauze packs § CBD opened using blade 12 about 1 cm, parallel to the long axis of the CBD § Exploration of the CBD done § Milk down any possible stones from the common hepatic duct into the choledochotomy incision § Perform the same maneuver on the distal CBD § Pass a Randall stone forceps of the appropriate size up into the right and the left main hepatic ducts § Pass a Randall stone forceps down to the region of the ampulla § Irrigate both the hepatic ducts and the distal CBD with normal saline solution using a Fr.16 NGT § Pass a No. 3 Bakes dilator through the ampulla. Elicit a “steel” sign.
SPHINCTEROTOMY/SPINCTEROPLASTY § Pass a Fr.8 feeding tube or a No. 4 Bakes dilator into the choledochotomy incision and down to the distal CBD, making sure you do not pass it into the duodenum § Palpate tip of the tube or the Bakes dilator through the anterior wall of the duodenum § Make a 4-cm incision in the lateral wall of the duodenum opposite the ampulla § Make a 10-mm incision through the anterior wall of ampulla at 11o’clock position § Explore distal CBD through the sphincterotomy incision § Do a complete sphincteroplasty § Place two 4-0 silk sutures on each lateral side of partially incised ampulla § Identify orifice of the pancreatic duct, which enters the back wall of the ampulla and avoid injuring or traumatizing it § Continue incising the ampulla for about 3mm at a time followed by placement of 4-0 silk interrupted sutures, suturing the duodenal mucosa to the mucosa of the ampulla § Place a figure-of-eight silk 4-0 suture at the apex of the sphincterotomy § Close duodenotomy in 2 layers by inverting mucosa with a continuous Connell suture and the seromuscular layer by interrupted 4-0 silk Lembert sutures § Cover the duodenotomy with omentum
T-TUBE CHOLEDOCHOSTOMY § A French 16 T-tube catheter, with shortened arm and wedge is excised opposite the main stem, is inserted through the CBD incision § Opening in the CBD about the catheter is closed securely by simple interrupted § Test for any leak by infusing warm saline through the T-tube § Bring T-tube out through a stab wound near the epigastric area § Suture the T-tube to the skin, leaving enough slack between the CBD and the abdominal wall § Peritoneal toilette done § Do cholecystectomy § Hemostasis done § Drain placed § Layer by layer closure © Peritoneum closed by continuos interlocking sutures using Vicryl-0 © Fascia closed by continous interlocking sutures using Vicryl-0 © Subcutaneous closed by Inverted T sutures using Chromic 2-0 © Skin closed subcuticularly using vicryl 4-0. § Dry Sterile Dressing applied § Patient tolerated the procedure well § Post-op condition- stable |