OR / Prep · Hepatobiliary Surgery · endoscopic
You’re scrubbing into
ERCP with sphincterotomy
Why are we operating?
Endoscopic drainage of the obstructed bile duct: cannulate the papilla, cut the sphincter, clear the stones, and in cholangitis, drainage beats everything else on the list.
Indication: Choledocholithiasis, ascending cholangitis, malignant obstruction for stenting; therapeutic, not diagnostic.
Read the imaging first
Practice before you scrub
Read the gallbladder
Fatty-food pain for months, now constant for 18 hours with fever. RUQ ultrasound. (Fictional educational case.)
- Stones plus an inflamed wall plus a tender probe is cholecystitis: the operation is laparoscopic cholecystectomy on this admission, not a deferred clinic date.
- The duct's calibre on the same scan sequences the pathway: dilated means the duct is interrogated before the gallbladder leaves.
The operation in 4 steps
01Reaching the papilla
A side-viewing duodenoscope is passed to the second part of the duodenum and the major papilla brought face-on.
02Selective biliary cannulation
A sphincterotome and guidewire are steered into the bile duct rather than the pancreatic duct, confirmed by wire course and contrast.
03Sphincterotomy and clearance
The biliary sphincter is divided with the sphincterotome along the eleven o'clock axis, then stones are swept with balloon or basket.
04Ensuring drainage
Clearance is confirmed on the cholangiogram; if the duct cannot be cleared or a stricture obstructs, a stent secures drainage.
Danger zones
Common bile duct
The structure every biliary operation is designed not to injure; misidentification is the field's defining catastrophe.
Right hepatic artery
Crosses the triangle aberrantly in about one in seven patients, hugging the cystic duct.
Duct of Luschka
A small subvesical duct in the liver bed; missed, it declares itself as a postoperative bile leak.
Anatomy you need
The scope's route: stomach, duodenum, then the ampulla where the biliary and pancreatic ducts share a door.
What can go wrong
Watch it done
ERCP with sphincterotomy
The endoscopic view: cannulating the papilla, the cut, and the stone coming out.
Source: Digestive Disease Center, Medical University of South Carolina · Watch on YouTubePutting the P in ERCP: pancreatic duct stenting, sphincterotomy and drainage
A teaching lecture on the pancreatic side of ERCP and the complications it is trying to avoid.
Source: Sheffield Gastroenterology · Watch on YouTube
Conceptual teaching for learners preparing to observe and assist under supervision, not operative instructions. Five minutes from now you should know why this operation exists, what its shape is, and which structures it is designed not to injure.