Gallbladder

(e) Interior of duct is explored upwards & downwards with the scoop for further stones. (f) Drainage of bite duct is carried out by means of a T-tube. Transverse limb is inserted in duct which is closed snugly about the vertical limb. Vertical limb is brought out thru a separate stab wound laterally.

Postoperative care (a) Note the character & amount of bile draining from the tube (which is collected in aplastic bag). (b) After 8th day tube may be clamped for increasing periods, & absence of pain & jaundice, & presence of bile in stools indicate satisfactory flow into duodenum. (c) Cholangiography is performed, & if there are no filling defects in a well-outlined duct & contrast enters duodenum freely, then T-tube can be removed.

(2) Transduodenal sphincterotomy Duodenum is opened in its 2nd part between stay sutures, & papilla & sphincter are divided at 10 o'clock.

(3) Choledochoduodenostomy STRICTURE OF BILE DUCT ETIOLOGY (1) Surgical trauma (postoperative) (2) Stones (3) Primary sclerosing cholangitis (4) Carcinoma of bile duct (5) Carcinoma of head of pancreas Postoperative Stricture It is the result of a preventable error in technique, during the performance of cholecystectomy: (!) Blind plunge application of a hemostat to a bleedingcys-tic or accessory cystic artery, or to right hepatic artery.

(2) Should cholecystectomy be performed by dissecting from fundus, loo much traction'applied to freed gallbladder may so tent the bile duct that any forceps intended for cystic duct grasp anguiated main channel.

(3) Failure to identify anatomy in Calot's triangle when there is much inflammation.

Common hepatic duct is tied instead of cystic duct.

(4) Ignorance of anatomical anomalies of bile ducts.

(5) Laceration of bile duct while exploration for stones.

(6) Injury to bile duct during partial gastrectomy.

CLINICAL PRESENTATION OF POSTOPERATIVE STRICTURE (1) Bile duct injuries may be recognized at the time of surgery.

(2) Postoperatively by: (a) Profuse & persistent discharge of bile if drainage has been provided. (b) Bilary peritonitis if drainage has not been provided. (c) Deepening obstructive jaundice.