It is the author's opinion that these very dilated common bile ducts without a stricture in their distal segment proven by operative cholangiography instrumental exploration, or choledochoscopy do not need to have either a bypass between the bile tract and the digestive trace or sphincreroplasty. In these oarienrs, as in all patients in whom an instrumental exploration of the common bile duce is performed, a Itube is left in place, which will allow us to onfirrn that there are no residual calculi and dye passes readily into the duodenum.
INTRAHEPATIC LITHIASIS
Intrahepaiic calculi chat are nm impacted or lodged in a diverticular sac or behind a stricture of the ducts can be removed by means of the diverse instruments used to remove calculi from the common bile duct. These are nallcablc spoons of different sizes modified Fogarty catheters, Dormia basket catheters of different sizes, or Randall calculi forceps catheters that can be managed through the supraduodenal choledochotomy dilating plastic catheters irrigations of physiologic solutions suction, and so on.
The flexible choledochoscope conrribures efficiently to the extraction of intraheparic calculi. Pluoroscopy with an image amplifier is also very useful since it assists in performing the maneuvers ro extract the calculi.
It is more frequent to find calculi in the left branch of the common hepatic duct because its diameter is greater and its direction more horizontal than the right brunch. In patients chat have irurahepatic calculi above a stricture of the ducts or lodged in a sacciform dilution of a segment of the left hepatic duct their extraction may be very difficult and sometimes impossible during the surgical procedure.
Removal of these calculi is usually performed postoperatively through the tract formed by the Tvtube. This removal should be performed by expert surgeons, in several sessions, following progressive dilation of the narrowed segments. When the surgeon is certain chat he or she has left intrahcparically due co not having been able to remove them, it is advisable to terminate the procedure with a choledochoduodenostorny, if the caliber of the common bile duct allows this, or if not by means of a sphincteroplastv, foreseeing that some of the calculi may spontaneously pass postoperatively through the common bile duct into the duodenum.
Before proceeding co remove intrahepauc calculi instrumentally, it is better co wait at least 4 months, since during this period calculi can spontaneously pass into the common bile durt. In some patients a large calculus may be retained in the left branch of the hepatic ducts.
Removal of this calculus the operative procedure can at times be attained by incising the left common hepatic dun where the calculus is present and removing it, as we will show later. Intrahcparic calculi are not frequently seen in countries hut are common in the Far East, especially in Chinese, Korean, or Japanese patients.
In these countries cholangitis is common and adds a very serious factor to the process, in some cases making it necessary to remove a segment of the liver or a hepatic lobe.