A 3 cm size stone in CBD near the ampulla of Vater is removed by
Ans. (a) Transduodenal ApproachRef: Sabiston 20th edition Page 1501Impacted stones at the ampulla that cannot be removed through choledochotomy or several stones in a nondilated tree can be addressed by a transduodenal sphincteroplastySteps:* Kocher maneuver,* Longitudinal duodenotomy is made on the lateral wall* Palpation of the ampulla to plan placement of the duodenotomy* After identifying ampulla- an incision made at 11' O clock* Avoid 5'O clock as pancreatic duct enters there.* The duodenal mucosa is sewn to the bile duct mucosa with absorbable 4-0 sutures.* A 1.5cm sphincterotomy is usually sufficient to allow stone removal and subsequent drainage.* Closure of the longitudinal duodenotomy in transverse fashion to avoid future duodenal stricture.
Trans duodenal approach
Supraduodenal approach
Chemical dissolution
ESWL
Gall Bladder & Bile Ducts