The biliary tree is intubated to accurately locate the papilla.
Access to the biliary tree is gained through a small opening in the cystic duct remnant or, if necessary, the common bile duct; the latter access can be avoided if you can confidently locate the ampulla by transduodenal palpation.
A 3-Fr. tapered, urethral filiform probe (or a small biliary Fogarty catheter) is passed through the common bile duct and into the duodenum to locate the papilla.
Suspicion of a common bile duct stone may require formal bile duct exploration. Rigid probes (e.g. Bakes dilators) should not be used, because the bile duct is vulnerable to perforation when papillary stenosis is present. Note the operator's left hand supporting the intrapancreatic portion of the common bile duct as the filiform passes through the papilla.
A 2-cm anterior duodenotomy is made directly over where the filiform leaves the papilla.
Stay sutures are placed at the 2 and 8o'clock position to elevate the papilla up to the level of the duodenotomy.
An incision is made along an 11 o'clock plane on the anterior surface of the papilla; use of small iris scissors facilitates transection of the sphincter - cautery should be avoided, because it obscures recognition of the mucosal edges.
Approximating the bile duct epithelium to the duodenal mucosa is carried out in sequential fashion with 5-0 polyglycolic acid sutures; the length of the sphincteroplasty (2-3 cm) should be determined by a point where the bile duct separates from the duodenal wall. Care must be taken to precisely approximate the bile duct epithelium and duodenal mucosa in this area.
Papillary stenosis often is associated with marked deformity of the transampullary septum (the tissue that separates the intrapancreatic bile duct from the pancreatic duct within the papilla of Vater).
The ostia of the duct of Wirsung can be difficult to visualize; it may be necessary to gently probe the inferior lip of papilla with the smallest of lacrimal probes.
Once cannulated, the ostia should be dilated with one or two larger probes.
The septum can then be divided safely by a sharp scalpel incision (11 blade) for at least 1 cm or to the point where the pancreatic duct measures at least 3 mm; deformity or scarring in this region may make this difficult.
A pancreatogram should be obtained at this point if not already done.
The mucosa of the pancreatic duct is approximated to the bile duct epithelium with interrupted 7-0 polyglycolic acid suture utilizing a small ophthalmic needle; this figure reveals what the papilla should look like at completion of the operation. Note that the anterior surface of the papilla has been effaced, and that the bile duct and duct of Wirsung enter the duodenum through separate openings.
The duodenum is closed in two layers with an inner row of a fine absorbable suture, placed in a running Connell, mucosal-inverting fashion, and the outer layer of interrupted seromuscular non-absorbable sutures are placed in interrupted Lembert fashion.
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