Transduodenal sphincteroplasty

Indications:
1.Impacted stone at ampulla of Vater
2.Papillary stenosis
3.Recurrent pancreatitis with multiple CBD stones

Contraindications:
1.CBD greater 2cm diameter
2.Long distal CBD stricture
3.Perivaterium duodenal diverticulum
4.Severe inflammation of duodenal wall or pancreatic head

Procedure for impacted stone:
1.Usually follows choledochotomy
2.Extended Kocherisation of duodenum
a.Peritoneum lateral to D2 incised
b.D2 retracted medially and inferiorly
c.Plane behind head of pancreas developed by blunt dissection
3.Longitudinal duodenotomy opposite ampulla of Vater at anterolateral aspect
a.Ampulla of Vater usually between upper 2/3 and lower 1/3 junction of D2
b.Exact location may be facilitated by palpation of stone or balloon Fogarty catheter passed down via cystic duct
c.Place stay sutures either side of planned incision to hold wall apart
d.Incise with diathermy through full thickness of duodenal wall
4.Locate ampulla of Vater
a.Usually mucosa folds circumferential in duodenum but this is lost at ampulla
b.Stay sutures are place either side of ampulla to elevate it
5.Ampulla is incised at 11 o’clock with needle tip diathermy
a.A small catheter is placed into the ampulla to facilitate incision on top of it
b.Incision of 5mm is made initially and fine 4-0 or 5-0 absorbable sutures are placed every 1.5mm incorporating duodenal mucosa and CBD mucosa. These are initially not tied and clamped by artery forceps to facilitate traction to open the CBD.
c.The incision is carried 5mm at a time for the length of the intramural portion of the CBD, which may be as long as 3cm.
d.The impacted stone may be extracted or pushed down by a probe passed from the choledochotomy
e.The incision stops when the mucosa of the CBD leaves the duodenum
f.Sutures are continued to the apex
6.Pancreatic duct opening is localised at 4 to 6 o’clock position
a.Once identified medial sutures are placed so as not to occlude it
b.Pancreatic duct orifice identification may be facilitated by giving Secretin 75 unit/kg iv to induce pancreatic secretion
c.If duct cannot be identified sutures are avoided between 3 and 6 o’clock
7.Once completed further choledochoscopic inspection is performed to ensure duct clearance
8.Longitudinal duodenotomy is closed with 3-0 PDS Lembert sutures in single layer
9.Choledochotomy is closed with 4-0 Vicryl interrupted sutures over a T-tube

Complications:
1.Acute pancreatitis
2.Bleeding
3.Duodenal leak from suture line