Avoiding inadvertent injury to the ampulla or distal bile duct during duodenal surgery

Every year we see a few cases where a patient has become yellow a few days after emergency surgery for a bleeding ulcer or trauma surgery involving the duodenum. The reason is usually a well meaning stitch to under-run an ulcer that has taken out and obstructed either the distal bile duct or ampulla or Vater.  Surgeons often forget how close the bile duct can run behind the posterior wall of the first part of the duodenum particularly when there is scarring from a posterior wall ulcer. Once this injury has been done it is difficult to undo. This type of injury can however be avoided so easily provided the surgeon has their radar on and is aware that by stitching an ulcer in the duodenum they could obstruct the bile duct.

The easy way to avoid this type of injury is to deliberately open either the cystic duct or common bile duct and pass a biliary Fogarty catheter down the bile duct and through the ampulla before stitching the ulcer. It is very easy to then see or feel the course of the catheter and thus the bile duct and to avoid injuring it by suturing it.  I would normally perform a  cholecystectomy at the same time and the additional morbidity from doing this is minimal compared with the genuine risk of inadvertent biliary injury or obstruction from blind stitching. If I go via the common bile duct I do not usually leave a T-tube in the bile duct and would do a primary closure using 4 or 5/0 PDS. You could leave a surgically placed stent in the ampulla but in my experience this is not usually necessary. Because the duodenum has been opened most people would leave a drain in the sub hepatic space and this is normally quite adequate.

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