Removal of gallstone entangled at the papilla. Kocher’s method of displacing the duodenum: a, incision in the paraduodenal peritoneum; b, pancreas; c, location of the stone; d, duodenum; e, sutures used either for retracting or closing opening in the common duct; f, retroduodenal venous plexus. (Kehr.)
These various cutting operations have superseded the previous methods of endeavoring to crush stones within the duct and force the fragments along by pressure. The Mayos have recommended the use of two fine parallel sutures, introduced longitudinally into the duct, between which the incision should be made, and which may be used as tractors, or subsequently for purposes of closure.
Practically every gall-duct case should be drained with a tube extending down to the deepest portion of the site of the operation. This may be done with what has been called a “dressed tube,” made by surrounding an ordinary rubber drain with a few layers of gauze and covering this with oiled silk. The lower end of the tube is then bevelled or trimmed in fish-tail fashion. This may be passed into the depths, or it may be used for gall-bladder drainage as well.
Of the anastomotic operations there is less heard now than a few years ago. There are now considered to be but a few conditions which are not better dealt with by biliary drainage as made above than by any other method. Occasionally, as, for instance, when the common duct is strictured or involved in pancreatitis or cancerous deposit, and bile is backing up into the gall-bladder, it may be of great advantage to effect an anastomosis between the latter and the bowel. At one time the colon was used for the purpose, but this prevented the utilization of the bile in the upper bowel, where it is most needed. Consequently it should always be made into the upper portion of the bowel, the duodenum, or one of the upper loops of the jejunum. For this purpose a small Murphy button is probably still the speediest and best expedient. This is true also when it seems necessary to drain the common duct into the bowel, since the field of operation in most cases lies too deeply to permit of accurate and satisfactory suturing. A further and more difficult as well as later application of this principle has been suggested for certain cases of permanent obstruction of the common and main hepatic ducts. Under these circumstances the operation last mentioned would be useless and a cholangiostomy would be objectionable, as it would constitute a permanent fistula. As practised by Kehr and others this hepato-cholango-enterostomy is performed by removing from the lower surface of the liver a strip of its tissue about 7 Cm. long and 2.5 Cm. wide. The hemorrhage is checked with the thermocautery, and with it an opening is made into the liver, of such a depth that several of the bile ducts are thus divided and opened. The uppermost loop of bowel which then can be utilized without tension is opened and sutured to the margins of liver wound. The method is still on trial, and yet in at least one successful case it was shown that the liver tissue tolerated this unavoidable contact with the contents of the upper abdomen ([Fig. 630]).
Fig. 630
Demonstrating the technique of anastomosis between the gall-bladder and the jejunum. (Cordier.)
After-management.
—What to do with these cases of biliary drainage after it has been effected is sometimes a serious problem. No hard-and-fast rules can be laid down regarding the length of time during which drainage should be maintained. In instances where the gall-bladder has been removed the drain should be taken out within thirty-six hours, but in those cases where a tube has been fastened into the gall-bladder for so-called permanent drainage the term “permanent” may be regarded as elastic, and covering a period of from ten days to perhaps ten weeks. In the majority of instances three weeks or so of such drainage suffice to meet the original indication. In cases, however, of chronic pancreatitis a long period of easy outflow will be demanded, while in rare cases of cancer drainage once thus made cannot be abandoned.