2. Stone extraction via the T-tube 89 3. Endoscopic method 89 4. Preparation for stone extraction 90 5. Technique 90 6. Results 91 7. Complications 91 8. Discussion 91 Index of Subjects 99 CHAPTER 1 INTRODUCTION This book was conceived as a descriptive atlas of most reliable indication for common bile duct ex­ routine biliary surgery i. e. , cholecystectomy and ploration. The cholangioscope allows a visual ex­ exploration of the common bile duct. For the pro­ ploration of the biliary tree and permits the re­ ject the two authors worked together for one week moval of common bile duct calculi and other as biopsy under direct visual con­ at Ninewells Hospital and Medical School, Dundee procedures such on a series of patients with biliary tract disease trol. Both procedures have been described in detail especially selected for the exercise. With the con­ with emphasis on the practical aspects of their use. sent of the Tayside Health Board and the patients The era of blind bilary surgery is over and the concerned, all the operations and peri-operative sooner this message is received by all concerned, procedures were filmed by the photographic mem­ the better the outcome of biliary surgical practice bers of the team, Mr. and Mrs. Paz-Partlow. Ad­ overall. ditional case material has been obtained from It has not been our intention to produce a com­ Cedars Sinai Medical Center, Los Angeles.

1. Introduction.- 2. Review of existing problems in biliary tract surgery.- 3. Surgical approach and principles.- 1. Introduction.- 2. Prophylactic measures.- 3. Pre-operative biliary decompression in the jaundiced patient.- 4. Operative principles.- 5. Drainage of the supracolic compartment after biliary operations.- 4. Operative cholangiography (in cooperation with J.A. Hamlin and M. Paz-Partlow).- 1. Introduction.- 2. Common bile duct explorations.- 3. Unsuspected stones.- 4. Cannulation techniques.- 5. Initial and/or completion cholangiograms.- 6. Standard technique.- 7. Fluoro-cholangiography.- 8. Anomalies of surgical importance.- 9. General aspects.- 10. Radiation protection.- 11. The cystic duct.- 12. Cholecysto-cholangiogram.- 13. The choledocho-cholangiogram.- 14. Contact selective cholangiography.- 15. Reason for failure for operative cholangiography.- 16. Artifacts.- 17. Complications of operative cholangiography.- 18. Reformed calculi.- 19. Complications of T-tube removal in the post-operative period.- 20. Results of operative cholangiography.- 5. Operative biliary endoscopy (cholangioscopy) (in cooperation with M. Paz-Partlow).- 1. Introduction.- 3. Technique.- 4. Endoscopic anatomy and pathology.- 5. Repeated cholangioscopy.- 6. Complications.- 7. General aspects.- 8. Evaluation of results.- 9. Conclusions.- 6. Biliary manometry and debimetry.- 1. Introduction.- 2. Usage.- 3. Pharmacolgy of the sphincter of Oddi (SO).- 4. Biliary pressure indices.- 5. Dynamic (transducer) manometry.- 6. Disorders of the sphincter of Oddi.- 7. Exploration of the common bile duct.- 1. Introduction.- 2. Technique of CBD exploration.- 3. Trans-duodenal exploration od CBD.- 4. Intra-hepatic calculi.- 5. Assessment of terminal end of the CBD and sphincteric region.- 6. Post-operative removal of T-tube.- 7. Conclusion.- 8. Postoperative removal of retained stones through the T-Tube tract (in cooperation with J.A. Hamlin).- 1. Introduction.- 2. Stone extraction via the T-tube.- 3. Endoscopic method.- 4. Preparation for stone extraction.- 5. Technique.- 6. Results.- 7. Complications.- 8. Discussion.- Index of Subjects.