Vher a calculus that is impacted in the papilla presents some difficulty in its removal the surgeon should not insist bur should recur co removal of the calculus by means of a iransduodenal sphincrerororny.
Insistence on removal of the impacted calculi by means of the supraduodenal chotcdochoromy can traumatize the papilla ieading to edema, hernatoma, laceration of the papilla, or a false tract. When a calculus becomes impactcd in the papilla, at firsr ic leads to spasm and edema of the papilla but later fibrosis develops, which craps the calculus. Sometimes ic is not only one calculus that is impacted but several small calculi, which join when they are soft in consistency forming a sort of pastelike obstruction.
In these cases, even though this pastelike material is removed, one is never sure that the papilla is free of calculi. The technique for the removal of calculi that are impacted in the papilla will be described later.
CALCULI LODGED IN A DIVERTICULUM-LIKE FORMATION OF THE DISTAL COMMON BILE DUCT
The localization of calculi in a sort of dlvcrticular sac ar the lower end or the common bile duct is not frequently seen but when present leads to difficulty in their diagnosis and removal. Exploring instruments do not find any difficulty in passing through the common bile duct and the papilla.
Sometimes these calculi can be felt, but since the explorers pass without difficulty to the duodenum it is believed that they are chronic pancreatiris nodules. A sure and objective diagnosis of chis localization only be obtained by means of operative cholangiography, which will show the presence of one or more calculi lodged in the diverticular sac.
At times these calculi are very adherent to the wall of the diverticulurn making their mobilization difflcult.
Attempts at removal of these calculi through the supraduodenal choledochotomy is usually a very difficult and dangerous task owing lo the lesions that can be provoked. In spite of the fact that these divcrticular sacs usually develop above the narrow zone of the distal common bile duct, with the passage of time the dilation usually extends into the narrowed zone.
The most appropriate technique to remove calculi in these diverricula is through a rransduodenal sphincteroromy, as will be seen lacer.