[Perduodenal Sphincterotomy (author's transl)]

In spite of immaculate surgical technique conventional transduodenal sphincterotomy is attended by a non-lethal complication rate of about 5.8% and a mortality rate of about 4.5%, the most frequent cause being dehiscence of the duodenal suture. The primary and secondary pathogenesis hereof is explained by the particular predisposition duodenal laceration on account of its special anatomy and operative vulnerability. Bearing these facts in mind, the method of so-called perduodenal sphincterotomy (p. sph.) seemed to offer more promising results for the following reasons: 1. Splitting of the sphincter through a minute incision in the duodenum (stab incision with a tenotome). 2. The advantage of primary closure of the cystic duct in the transcystic approach with medium-sized probes for the splitting. Experimental evidence shows the cystic duct to be very resistent towards dilation and rupture, especially in the presence of inflammatory processes. From 1967 to 1973 in 1441 cases of gall-bladder surgery p. sph. was performed 374 times and transduodenal sphincterotomy only 121 times. The statistic evaluation of the outcome of both methods showed significantly better results with p. sph. with regard to the incidence of postoperative non-lethal complications and duration of hospitalization. Assessment of non-lethal postoperative mortality and follow-up studies on 79% of the operated patients over a period from 3 to 9 years showed that the results of both methods were equal. In our experience the p. sph. is not only advisable when sphincterotomy is generally indicated, but also in the following special situations: a) as so-called "emergency papillotomy" in poor-risk patients; b) if the transduodenal approach is impossible awing to technical difficulties (poor accessibility, low site of the papilla); c) if the indication for papilotomy is dubious it can be chosen as the less dangerous method; d) for reoperation on the sphincter. On account of its prevailing advantages this new method for repairing papillary drainage is practicable as a routine method in sphincteric surgery.