. Manual of operative surgery. this can be much simplified by exerting counterpressure onthe duodenum and pancreas. Ducts not large enough to admit the fingerare usually thin-walled, not much adherent, and hence palpable from theoutside. It is only in difficult cases, , where many adhesions are presentand the duct-walls are thickened, that finger exploration inside the duct be- cholp:i)ochotomy 579 comes absolutely necessary. In all cases when it is possible, this methodof exploration should be used. Diverticula hide stones from the probe orscoop, as the nature of the calculi lets them giv
. Manual of operative surgery. this can be much simplified by exerting counterpressure onthe duodenum and pancreas. Ducts not large enough to admit the fingerare usually thin-walled, not much adherent, and hence palpable from theoutside. It is only in difficult cases, , where many adhesions are presentand the duct-walls are thickened, that finger exploration inside the duct be- cholp:i)ochotomy 579 comes absolutely necessary. In all cases when it is possible, this methodof exploration should be used. Diverticula hide stones from the probe orscoop, as the nature of the calculi lets them give no feeling of grit whentouched by metal; only the finger can recognize them. Step 3.—Treatment of the wound in the duct. (A) If it is possible to do a cholecystostomy, and the cystic duct is suflicientlypatent to permit of biliary drainage, the wound in the duct may be treatedas follows: Cross the one end of suture x with that of suture y (Fig. 706),and the end of suture x^ with that of suture y^ but do not tie them. Place. Fig. 705.—Choledochotomy. {Mayo.) From sketches by the author. the strip of gauze G (Fig. 707) longitudinally over the wound in the duct andover the crossed sutures. Tie the sutures around the gauze strip, the freeside of which is covered by a layer of rubber tissue. This closes the woundand fixes the gauze over it, so that should bile escape it cannot wash awaythe gauze and, an eflScient drain is provided. Bring the end of the gauze outthrough the abdominal wound. A folded strip of rubber dam or gutta-perchatissue is preferable to the gauze. Establish a cholecystostomy. Close theexcess of abdominal wound. ^) If owing to the small size or the diseased condition of the gall-bladdera cholecystostomy is impossible or improper, proceed as follows: Preparea 3^-inch tubular drain wrapped with gauze to within a distance of 3^-inchof its end. Introduce the bared end of the tube into the common duct; thecovering of gauze prevents its going in too far. Thread on
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