Expose and prepare the bile duct for exploration, as detailed in Chapter 63. Place two stay sutures and make a longitudinal incision in the lower third of the common duct. Make the incision approximately 2 cm in length and just above the appearance of the common duct over the superior aspect of the duodenum. Place the incision lower than you normally would for common duct exploration to facilitate construction of the choledochoduodenal anastomosis. Explore the common duct thoroughly.

The close proximity of the distal bile duct and duodenum make this anastomosis possible. Extra mobility of the duodenum may be obtained by performing a Kocher maneuver.

Place stay sutures on the anterior duodenal wall just below the entry of the bile duct into the duodenum. Center a longitudinal duodenotomy above the choledochotomy on the anterior superior surface of the duodenum. Make this incision approximately the same length as the incision in the bile duct.

The two incisions will be perpendicular to each other and will produce a diamond-shaped opening when sutured together. Place a posterior interrupted row of 4-0 silk Lembert sutures, beginning at the apex of the choledochotomy and continuing laterally in both directions. This will form the back wall of the anastomosis. Interrupted mucosal sutures of 4-0 Vicryl can be placed if desired. Next, suture the anterior row with interrupted sutures of 4-0 Vicryl on the inner layer and interrupted 4-0 silk on the outer layer. Alternatively, a single layer of interrupted 4-0 polydioxanone (PDS) sutures may be used.

Do not stent the anastomosis or place a T-tube or other drainage device in the common duct. A lumen should be palpable to the tip of the finger at the conclusion of the procedure. Place omentum around the choledochoduodenal anastomosis and then place two closed suction drains (generally, one on each side) in the vicinity of the anastomosis.