Tricks of the Senior Surgeon

■ The major papilla (ampulla) of Vater is often palpable through the duodenal wall even without a transcholedochal (e.g., via cystic duct) catheter through the Ampulla of Vater.

■ The accessory papilla is proximal in the duodenum, perhaps only 3 cm from the pylorus; a prominent vessel on the lateral duodenal wall is often noted at this point.

■ The transverse duodenotomy provides adequate exposure and is less likely to cause postoperative duodenal stenosis than a longitudinal suture line.

■ The accessory papilla may be difficult to find by visual inspection, it is often small, protrudes minimally from the duodenal surface and is located more easily by gentle palpation of the medial wall of the duodenum. It feels like a small "bump" or nipple.

■ Application of methylene blue to the duodenal mucosa may help to locate the pancreatic duct orifice; pancreatic secretions, especially after secretin, wash off the blue dye at the orifice.

■ After cannulating the orifice, do not remove the probing instrument until the incision into the papilla has been completed. Local trauma may make rediscovery of a small, traumatized orifice very difficult.

■ The dorsal duct of Santorini follows a perpendicular course through the duodenal wall (in contrast to the oblique path of the duct of Wirsung); the sphincteroplasty is therefore necessarily short. Going past the thin membrane of the first centimeter makes the apex of the sphincteroplasty difficult to suture.

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