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Contents

Contents Gallbladder and Biliary Tract Cbolecystectomy :1 Common Duct Exploration J() Sph inctcroplasty, Including T

Gallbladder and Biliary Tract

Cbolecystectomy

:1

Common Duct Exploration

J()

Sph inctcroplasty, Including T ransampullary Common Duct Exploration

Side-to-S ide Choledochociuodeno'lomy

28

l."i

Re section of a Benign Bile Duct St ri ct ure Wit h i<eco nst ru ction Ut ili ting Siiaslic Transhepanc Biliary

Stcnts a nd He pa t icojejunos tom y

38

Resec ti on of a Prox imal Cholangiocarcinoma With Reco nstruct ion Util izing Silastic Transhepati c

Biliary Ste nts an d Bilateral Hepaticoj ejunostom ics

58

Resection of a Proximal ChoiangiocarcinolllCl With Hepa tic Lobectomy and Recon st ru ction l :tiiizinga

Silastic Tran shepat ic Bili ary Stent and Hepat icojejullostomy

72

Prox im al Choiangiocarcino rn a: Palliation by Tran shepat ic Stcnting and H epaticojejunostomy

I~ esec tion of H epat ic Duct Bifur cat ion. Dilatation o f In trahepatic Biliar y Tr ee. and Prol onged

Stenling With Transhepatic Bil iary Stent s for Sclerosing Cholangitis

94

Hepaticojej unostomy for Distal St

Resect io n 01 Choledocha l Cyst

ri c tur ing Seco nd a ry to Scle rosing Cho langitis

116

Transhepat ic Sle nling for Caroli 's Disease'

l28

lOll

SJ

Wedge Resection of Liver and Reg io na l Lymph Node Di ssec tion for Carcinoma of the

and Reg io na l Lymph Node Di ssec tion for Carcinoma of the Gallbladder I-U

Gallbladder

I-U

The Liver

Anatomy of the Li\'er

152

:\onanatomical Liver Resect ions 156 Resection of Lateral Segme nt of Left Lobe of Liver 162 Resection 01 Left Lobe QI Lil'er J(jll Resection of Right Lube of Li\'er 178 Resection 01 Right Lobe of Li\'er Plus \Iedial Segment 01 Left Lobe ITrisegmentectomy I 19(1 Insertion of Infusaid Pump for Hepat ic Artery Inlusion 20() Resection of Simple C\,st of Lilw 206 \Ianagem ent 01 Hydatid Cyst Disease of Liwr 1](1

f Li\"~;!".-\b5('e3ses :!2.J

Draina~

Portasyste mic Shu nts Interposition Mesocaval Shunt 252 Distal Splenorenal Shunt 266 Portacaval Shunt 274
Portasyste mic Shu nts Interposition Mesocaval Shunt 252 Distal Splenorenal Shunt 266 Portacaval Shunt 274

Portasyste mic Shu nts

Interposition Mesocaval Shunt

252

Distal Splenorenal Shunt

266

Portacaval Shunt

274

End·to·S ide

276

Side·to·S ide

282

Interpos it ion " H" Graft

286

Direct Mesocava l Shunt 288 Mesoa trial S hunt 2 98 Le Veen Shunt 312

The Pancreas

Longitud inal Pancreat icojejullosto my: Pu es lOw Procedure

326

End·to·End Pancreaticojejunostorny: DuVal Procedure

342

Dista l Panc reatectomy fo r Chro nic Pancreatitis

350

Ninet y-Fi ve Pe rce nt Dista l Panc reatectomy for Chronic Pancreatitis

Ac:ces~ory Duct Papillolom y for Pancrea s Divi s um

366

Drainage of Panc reatic Pseud ocyst into Roux ·en·Y Jejunal Loop

370

Dra inage of Panc reatic Pse udocys l into the Stoma c h Drainage of Panc reatic Pse udocys t into the Duodenum

380

384

362

Pancreaticoduoden ectorny (Pylorus· Preser ving Whipple Procedure)

Palliative Bypasses for Un

resectable Periampullar y

Cancer

414

Distal Pancreatectomy for Tumor

428

386

Laparotomy for Insulinoma

436

Drainage of a Pancreati c Abscess

442

Diverricu larizat ion of the Duodenum and Pancreatic Drainage for Combined DuOOer

Trauma

454

a1

and Pancrr

Pyloric Exclus ion and Pancreatic Drainage for Combined Duodenal and Pancreatic Trauma ~

Gallbladder and Biliary Tract

Gallbladder and Biliary Tract - '~ --''''''''''

-

'~ --''''''''''

Cholecystectomy Operative Indications P atients with symptomatic gallstones are candidates for cholecystectomy. In the

Cholecystectomy

Operative Indications

P atients with symptomatic gallstones are candidates for cholecystectomy. In the past even patients with asymptomatic

gallstones were thought to require cholecystectomy. Howe\'<7,

recent

natural history data suggest tha t unless patients with symptoms referable to their biliary tract, the likeljbrxxJ

ga llsto nes have

developing significant morbidity is low enough to justify merely t - patient and performing cho lecystectom y onl y if symptom arise. There::JaY be exceptions to this rule . An individual living in or tra ve li ng to remorearea" where medical care is not readily available may be a candidate for prophylactic cholecystectomy if stones are present. Other factors such a diabe or other systemic illnesses may also modify thi s decision. Most patients wilh asymptomatic gallstones, however, are no longer considered candida

cholecystectomy. Some patients with sy mptomatic gallstone dis ease may

extracorporeal shock wave lithotripsy. At present, however, thi represents only

a minority of patients with symptomatic gallstones ; the majority

by cholecystectomy. There are also other rare indi cations for cho

other than symptomatic calcu lus di sease. Indi vidual s who are ha";';"""= Infusaid pump inserted for the management of colorectal meta (0 the IDW routinely undergo cholecystectomy. In addition, patient undergoir: palliative transhepatic stenting of their biliary tree at the time of urgery also undergo cholecystectomy because of the risk of subsequent cho eqs - -

Operative Technique

be man

lIoith

are managed

ecystectomy.

C holecystectomy can be performed through a right

ubcos

. upper

midline, or right paramedian incision. The right ubcos incision is

preferred . Once the abdomen is entered , the peritoneal ca -',- '"

explored for evidence of other pathology. When none' . the

surgeon proceeds with the cholecystectomy. Exposure i greatly facilitated if an

upper hand retractor is used to retract the skin, subcutaneous tissues. and costal margin. A Deaver retractor then easily exposes the under"'<;'" liver (A).

::he

Hepatic flexure of colon 3

Hepatic flexure of colon

T he hepatic

flexu re of the colon is ret racted in a caudal di rection,

frequently wit h a Mi k uli cz pad , a nd the stomach is packed medially , also wit h a Mikuli cz pad. A clamp is pl aced on the fund us of the gallbladder, and it is gen tly retracted in a ceph alad direct ion. T hesero a

overl ying the porta hepati s is opened and the por tal st ru ct ures ident ified (B).

The cystic duct is identified a nd looped with a vesse l loop. If it is doubly looped, thi s will preve nt ga llbl adder stones from pass ing through the cys tic duct into the common duct du rin g gallbladder manipul ation (C). Dissection of Ca lot's tri angle allows identifica t ion of the cys tic ar te ry,

which arises from the common hepatic or righ t hepatic artery. Thi s anatom y

is

extremely variab le, and t hi s area has to be dissected clearly identify the cys tic duct and cystic artery and

ca refully and completel y to avoid injuring

to

ano malou s st ru ct ures . T he right hepatic arte ry fr eq uentl y fo llows the cys tic duct and/ or gallb ladder very closely before cu rving back up in to liver parenchyma, a nd fo r a 1· or 2·cm course it ca n eas il y be confu sed with the cystic artery. The arteri al anatomy has to be dissected s uch that t he cystic arte ry is clearly seen joining the ga llbladder before one can be certa in of its ide nt ifica tion. Likewise t he cystic duct, which us uall y arises from the common hepatic duct , may arise from the righ t hepatic duct or from one of th e two segmenta l duct s to t he right lobe of the liver. Thi s area ha s to be carefu ll y and completely di ssected to be certain of t he anatomy. If the anatomy ca nnot be clearly delineated, one s hou ld stop fur ther dissec tion in th is area and proceed to mobili ze the gallbladder from above downw ard . When th e gall bladder has been mobilized out of the li ver bed, the

anato my

injecting contrast directl y into t he ga ll bladder or ductal system, may al so be

hel pful.

of thi s area will become clear. Early cholangiography, perform ed by

he:Jabc a Cystic duct Cystic a. and duct

he:Jabc a

Cystic duct

he:Jabc a Cystic duct Cystic a. and duct

Cystic a.

and duct

A transverse abdominal incision is made in the anterior axillary line, approximately 2 inches below the costal margin. In a particularly cachectic individual with no su bcuta neou s tissues, the valve may be inserted in the rectus sheath and covered by the rectus muscle. In

most instances, however, the valve is inserted lateral to the rectus sheath. The transverse incision in the right axillary line is deepened down to the external oblique muscles, wh ich are spread in the direction of their fibers (C).

The internal oblique muscles are then separated in the direction of their fibers (D), and the transversus abdominis muscle fibers on the peritoneum exposed. In preparation for passing the tubing from the va lve, in a cephalad direction, a small opening is made through the abdominal wall muscle layers into the subcutaneous space (D).

~ _ ~ ~~ Cysbc a
~ _ ~
~~
Cysbc a

Cystic a. and duct

~ _ ~ ~~ Cysbc a Cystic a. and duct R hepabc a Cyshc duct \

R hepabc a

Cyshc duct

\

~ _ ~ ~~ Cysbc a Cystic a. and duct R hepabc a Cyshc duct \

-- -J

Serosal reflection - -

Mobilized
Mobilized

gallbladder

~ _ ~ ~~ Cysbc a Cystic a. and duct R hepabc a Cyshc duct \
O nee [he gallbladder has . I mobiJim:I out of the liver bed, [he anatomy

O nee [he gallbladder has

.

I

mobiJim:I out of the liver

bed, [he anatomy i generally dear, and if the cystic artery has not

been previou ly identified, control of that vessel can now be

accomplished. Controversy remain as to whether or not routine

cholangiography sho uld be performed. Our bia i that selection hould be used and that not all pa t ients need unde rgo operat ive chol angiography. If one is

operat ing upon a patien t wit h normal li ve r funct ion tests and a single, large choleste rol gall s tone, the like li hood of common du ct sto nes is so Iowa to be negligible, and operat ive cholangiography is unnecessa ry. In a significant propor tion of patients un dergoing cholecystectom y, however , uperative

chola ngiograp hy will

Afte r pl ac ing a t ie proxim a ll y a t t he cyst ic d uct-ga ll bladder ju nction, a s ma ll open ing is made di s tall y in t he cys tic du ct a nd a cholangiocatheter inse r ted (H). The cholangiocat heter is secured with a 2- 0 si lk that i tied around the dista l cyst ic duc t containing the cath eter and then passed th rough the ope ning on t he cat heter.

be requir ed.

Af te r ade qua te

removed, the cyst ic

removed The co ntin ue

for gall s tone form a tion and thu s use a sy nth et ic a bsor ba bl e ma te ri al. T he r ight upper quadra nt is copiously irrigated wit h an an tibiotic

conta ini ng sa lin e solution. Hemos tas is in t he bed of

the elect rocautery. Whethe r or not to dr ain th e li ver bed and porta hepati s following routine

the li ver is achieved with

acting a a nidus

urgeons

cholang iograp hy ha s bee n ob t ain ed, the chola ngiocatheter is duct is doubly clamped a nd di vided , a nd th e gallbladder is

from t he operat ive field (1).

cystic duc t s tump is th en ligated with a 2-0 silk (J ). Many

to use sil k,

as we do; oth ers are concern ed a bou t it

cholecystecto my rema in s somewhat con troversial (K). T he re are vir tually no

signi ficant liab iliti es from drain ing cholecys tecto my, bu t many stu di es

reaso n for lea ving a drain behind is if an

sma ll , unr ecogn ized bile ductule in the bed of t he li ver; lea ving drain in place

obv iates the need for reex ploration. If drain s have not been placed, this can

prese nt a seriou s life -th reate nin g complica t ion. Even th ough rare, it seems to us

that the disco mfo rt of a dra in threaten ing compli cati on . We

hours. If bili a ry drainage does not occu r , t he drain is rem oved ju t prior to

discharge.

t he operat ive site following elective

have s how n it to be unn ecessary. The only

unexpected bile leak occur

from a

is wort h the avoidan ce of t his unusual but life-

pref er a clos ed

sucti on drain left in place for

_I Cyst ic duct -- - ~~ tiI' Co mmon hepatic duct C-a -·adder fossa
_I
Cyst ic duct -- - ~~ tiI'
Co mmon
hepatic
duct
C-a -·adder fossa -- - --- - -- ---Jr-'ir.
Cystic a. and
duct stumps -- --,~ '7"
Common Duct Exploration Operative Indications M ost common duct explorations for calcu li are performed

Common Duct Exploration

Common Duct Exploration Operative Indications M ost common duct explorations for calcu li are performed in
Common Duct Exploration Operative Indications M ost common duct explorations for calcu li are performed in

Operative Indications

M ost common duct explorations for calcu li are performed in

conjunction with

cholecystectom y. In t he past, patients who bad

previously undergone cholecystectom y and presented with primary

or recurrent common duc t stones were al so t reated surgically_

Now the majority of such

endoscopic papillotomy. Thus today the only patients wit h common duct caIaili who routinely are treated surgically are those patien ts with a gallbladder in place who also require cholecystectomy.

patients can be managed nonoperat ively with

The most common indication for common duct explora tion today i

the

radiographic demonstration of stones

patients in our institution who present with jaundice have their biliary tree

anatomy and pathology delineated cholangiographically prior to surgery. This is ca rried out preoperatively via either endoscopic or percuta neous tr an hepatic cholangiography. However, in the event that cholangiograph y has not been performed preoperatively, operative cholangiography is performed at the timed

s urger y in most patients who prove to have biliary trac t stones . Common dud

exploration in the absence of preoperative or intraopera tive chola ngiography is

infrequent in our institution. At the time of elective cholecys tectomy, if a is u nexpectedl y palpated in the biliary tree or a dila ted com mon duct is

u nexpectedl y found, the patient would undergo

dem onst ra te the entire biliary tree prior to common du ct explora ti on.

Operative Technique

in the biliary tree. T he major ity

of

tone

operat ive chola ngiograph y to

O nce t he decision is made du oden um is koch eri zed

to perform a com mon du ct exploration. the ex tens ively (A). Th is all ows one to palpate

t he dista l common du ct as it t ra ver ses beh ind the first portion of the

duodenu m and hea d of t he pa ncreas, prior to entering the di tal

second por tion of the duode num t h roug h t he am pu lla. It is impossible to adequately palpate t hi s por tion of t he bil ia r y t ree wit hout exte nsive

kocherization. The common duct is cl eaned fo r a 2· or 3·cm length , generaUy between the cystic duct stump and the duodenum . tay sutures of 5-0 synthetic nonabsorbable material are placed in the common duct, and a choledochotomy is performed (B). The choledochotomy hould be of ample length, at least 1 e m, to allow ea y in trumentation of the duct without traumatic exten ion. lOnes are often pontaneou Iy evacuated a bile i ues forth from the common duct opening. At the same time any tones that are palpated in the distal common duct can be milked up toward the choledochotomy and reIIIO'13I

C,_

, :;:?'----- Cystic a and duct slumps -'.C±,C- ----,----- -- -- Common duct Cyst ic
, :;:?'----- Cystic a and duct slumps -'.C±,C- ----,----- -- -- Common duct Cyst ic
, :;:?'-----
Cystic a and duct slumps
-'.C±,C- ----,----- -- -- Common duct
Cyst ic a.
and
duct
Choledochotomy
Kocherized
duodenum
Common duct stone

T here are a variet y of in struments that one can u tilize to explore the biliary tree; generally we utilize all of these instruments in an effort

to completely rid t he tree of biliary

calculi. It is important that the

choledochotomy be made

used to extract biliary calculi do not

adequate in length,

traumatica ll y extend the inci sion.

so that the in strum ent

A variety of scoops with malleable ha ndles can be used to pass distally

down to the ampulla and up into the intrahepatic biliary tree via both the r ight

and left hepatic ducts (D). These scoops come in a variety of sizes and can be extremely effective in removing small stones or biliary sludge. Randall Stone forceps are also utilized, and many surgeons use these instruments initially in the duct exploration (E). These forceps come with a variety of curves that range from almost st r aight, as pictured here, to righ t- angled and even acute-angled. These instruments are very effective in grasping larger, well-formed stones. The bil iary balloon catheter is particu larly usefu l; it can be passed down

dista lly, through the ampulla , and then inflated to document

dista l biliary tree into t he duodenum. This is perhaps the safest way to demonstrate an open ampulla. In using the balloon ca t heter, one has to be carefu l that it is not overdistended. Experimental studies have demonstra ted intrahepatic ductal disruptions and liver abscesses formed from overinflation of the balloon. If one constantly moves the catheter to and fro as the balloo n is inflated, being certain that the balloon catheter remains mobile within the ductal system, overinflation is un li ke ly. T he balloon catheter is part icularl y effective in retri.eving intrahepatic stones (F).

patency of t he

/ '---_ _ Small stones and sl udge - - 4 Bwary balloon cathet er

/

/ '---_ _ Small stones and sl udge - - 4 Bwary balloon cathet er --
'---_
'---_

_

Small stones and sl udge

- - 4
-
-
4

Bwary

balloon

cathet er -- -

I

I

Inlrahepa 'c

stone

_ Small stones and sl udge - - 4 Bwary balloon cathet er -- - I

Randa ll

Stone

forceps

_ Small stones and sl udge - - 4 Bwary balloon cathet er -- - I

O ne of t he most effective maneuvers in ridding the biliary tree of

stones and biliary sludge is irrigati on us ing a small French cath

A

#12 French ca t he te r pla ced intrahepaticall y into the righ t and I

hepatic ducts, together with large volume irrigation with saline, is

extrem ely effective in ridding th e entire intra hepati c

(G). This maneuver can also be carried out distally . Passage of the French catheter through the ampulla into the duodenum is a safe way of demonstrating ampulla patency (H). The use of Bakes dilators is controversial. Man y s urgeon s feel that the

potential

postoperative pancreatitis is so great that these metal dilators sho u ld never be used. Other surgeons feel it is accep tabl e to carefully and gentl y ut ilize the

smallest Bakes dilator to demon st rate patency of the

dilatation). Our philosophy is that it is safer to demonstrate patency of the ampulla with either a balloon catheter or a small Fren ch ca t heter. Ii neither of these is effective in demonstrating patency of the ampull a, then very cautious and gentle use of a small Bakes dilator is accep table. Generall y the Bake dilator easily passes gently through the ampulla, and patency can be dem onstrated by seeing the "steel gray" end of the dilator pressed agains t the la teral wall of the duodenum (1). We feel there is rarel y an indica t ion fo r the use of a Bak dilator larger than a #3.

biliary t ree of

mall st

for creating fa lse passages , injuring the ampulla , an d/or in itiating

am pulla onl y (a nd not for

\ Irriga 'on catheter >   Catheter tip .a_--'-'_ _ through   ampulla ~3 Bakes

\

Irriga 'on

catheter

\ Irriga 'on catheter >   Catheter tip .a_--'-'_ _ through   ampulla ~3 Bakes

>

 

Catheter tip

.a_--'-'_

_

through

 

ampulla

~3 Bakes

dilator

_I

_ats-g.,y

M any biliary t r act s urgeons ha ve adopted the routine use of

choledochoscopy during common duct exploration. T hi

can be

carried out with either a rigid right·angled scope or a flexible

fiberoptic instrument. Many studies demonstrate that operative

choledochoscopy signifi ca ntly lowers the incidence of retained common duct stones. The rigid scope is easier to use but allows one to visualize a relatively

smaller proportion of the

The flexible scope is more difficult to use, but it allows the su rgeon to visualize a greater extent of the intra· and extrahepatic biliary t ree (K). With either instrument one can utilize balloon and basket catheters to remove stones visua lized in the biliary tree (in sets). Following comp letion of the common duct ex ploration, a T- tube should be inserted routinely. Our preference is for the variety of T - tube with a larger diameter external limb and a sma ller diameter T. We fur ther decrease the size of the T by cutting off the back wall. A wedge shou ld also be rem oved from the

back wall to allow collapse of the two T - li mbs whe n t he T -tube is removed (L

intrahepatic and extrahepa t ic biliary tree (J).

Following in sertion of

the T -tube, t he choledochotomy is closed with a

continuous suture. Many surgeons feel that synt hetic absor ba bl e materi al, either 4-0 or 5-0, should be utilized to elimi nate the theoretical possibility of a permanent suture material acting as a nidus for stone formation. Other, however, have utilized silk, or even synthetic nonabsorbable material, without any obvious adverse effects. The T -tube should be brought stra igh t out laterally, withou t s harp turns

to allow for easy identified (M).

Closing cholangiography should always be performed. If filling defect

suggestive of stones are seen, the duc t exploration emergency situations, the su rgeon shou ld not rely

stone extraction to s ubstitu te for a completely s uccessfu l operati ve procedure. If contrast does not enter the duodenum, glucagon should be admini stered. If

repeat cholangiography sti ll does not demonstrate contra st in the duodenum, the surgeon should consider opening the duodenum and performing a sph incteroplasty (demons tra ted on pages 18-27) to be cert ain there is not a ampullary stone. The area of t he choledochotomy is drained with Penrose or closed suction drains.

s hould be repeated . Except in

instrumentation s ubseq uentl y if a reta ined stone s hould be

upon postopera t ive mean

of

J Rigid ;.- choledochoscope Bilia ry f- balioon calheler
J
Rigid
;.-
choledochoscope
Bilia ry
f-
balioon
calheler
J Rigid ;.- choledochoscope Bilia ry f- balioon calheler 0;--;.----- Choledocholomy closure
0;--;.-----
0;--;.-----

Choledocholomy

closure

Sphincteroplasty, Including Transampullary Common Duct Exploration Operative Indications S phincteropl asty is an

Sphincteroplasty, Including Transampullary Common Duct Exploration

Operative Indications

S phincteropl asty is an operative procedure that h as been u sed in a

Thi s is now cons idered only a rare indication in

variety of settings over the past several decades. For many years it was

utilized as treatment for recurrent acute and/or chronic pa ncreati tis .

an unusual in stance

where the pancreatitis appears to emanate from a proximal pancreatic duct structure. Some surgeons feel that sphincteroplasty should be added to papillotomy of the accessor y papilla w hen s urgically treating a patient w ho has recurrent abdominal pain secondary to pancreas divisum. Recently there has

been some enthusiasm for sphincteroplasty and septotomy of the pancreatic

duct orifice for the ma nagement of patients

abdominal pain , perhaps second ar y to stenos is of t he pancreatic ductal orifi ce.

Sphincteroplasty has also been utili zed for calculus disease of the bili ary tract. If after a common duct exploration the surgeon is not ce rtain that all of t he stones have been removed, some s urgeo ns have s uggested openi ng the duodenum and performing a sphincteroplasty so that any retained stones may

pass spo ntan eous ly. It is still used frequ ently for patients who have an distal common duct stone t hat cannot be retrieved from above t hrough

chol edochotomy. A sphincterotomy is performed to dis impact the stone , and

most s urgeon s will proceed to extend to the incision and convert it in to a form al

with refractory postchol ecystectom y

im pa cted a

sphin cteroplasty. patient is treated

Most of these patients are now ma naged with endoscopic papillotomy. If tha t is unsuccessful and the patient requires laparotomy, most biliary tract surgeons now feel t ha t it is impor tan t to add a dra in age proced ure to com mon duct exploration a nd stone extraction in many of these patients. Sphincteroplasty can be successfully used as the drainage procedure. Finally, we h ave ut ilized sp hincteroplasty in recent years as a means of exploring a common du ct for calcu li when the common duct is of norm a l or s ma ll ca liber. Common duct exp loration through a choledocho t om y and

su bsequ en t T - t ube in se r t ion carries sign ificant morbidity if the diam eter of the bil e d uct is s mall. Ex plor ation through t he ampulla is a good a lte rn ati ve . T he

ope rative procedures

as well as retrograde comm on du ct exploration th rough the s phincteroplasty

mClSlo n .

Man y biliary t ract s urgeons utili ze s phincteroplas t y if a operatively for a recurrent or primary common duct s tone.

of sph incte roplast y a nd septotom y will be dem ons trated ,

Operative Technique

T

he abdomen i entered through a right ubcostal incision. If the gallbladder i in place, a cholecystectomy i perlormed (see pages 2- 9). After the gallbladder has been mobilized, if operative cboIangiograpby

is required. It IS performed.

~43i~

-

~43i~ - BIliary balloon catheter ~ ~ ~~ ---' "---"-'=--';-- ~ ~,--,-- .:!l~~-=-,2_- :;;_;_~

BIliary

balloon

catheter

~ ~ ~~ ---' "---"-'=--';-- ~ ~,--,-- .:!l~~-=-,2_- :;;_;_~
~ ~ ~~
---' "---"-'=--';--
~ ~,--,--
.:!l~~-=-,2_-
:;;_;_~

Kocherized

duodenum

Balloon

inflated in

duodenum

Cystic

du ct

He ad o f Panc re as

A fte r t he dec is ion ha s bee n made to perfor m a s phincteropla ty, a small

opening is made in the cystic du ct , a nd a balloon catheter i

inserted

in to t he common duct, di s ta ll y

duodenum

(A). The duodenum

through th e a mp ull a and into the is th en kocheri zed, and following

balloon inflat ion, the area of the ampu ll a can be identified by palpat ion . The

longitudinal duodenotomy is placed directly over the point where the

palpates the balloon . After stay sutu res of 3- 0 silk are placed in the du odenu m, the balloon

catheter is advanced beyond t he ampulla so as not to perfo rate the balloon the duodenotomy is performed (B).

urgoon

Th e duodenotomy is perform ed w ith the electrocau tery. After

t he

duodenotomy opening is made, by palpation t he surgeon ca n iden t ify the ballkx:lD

(C) and the location of

t he ampulla.

~

----;_ + -,
----;_
+
-,

uu.ny

Balloon

advanced

.c

~ ----;_ + -, uu.ny Balloon advanced .c
O nce t he location of the ampulla has been identified, the i extended. tay

O nce t he location of the ampulla has been identified, the

i

extended.

tay sutures of 5- 0 synthetic absorbable rna

cath eter as a guide, a

sph incterotomy is perfor med at 11

cath eter as a guide, a sph incterotomy is perfor med at 11 . 3!i placed
. 3!i
.
3!i

placed at 3 o'clock and 9 o'clock on the a mpu ll a. Using the ba!lioor

120'

with the electrocautery (D). The opening is made 3 or 4 mm at a . Once the ampulla has been opened , the ductal mu cosa i utum:l1D duodena l mucosa with a series of interrup ted 5- 0 synthetic absorbable~~A (E) . T hese sut ures are gathered in hemostats; their ret raction .

expos ure of t he area Aft er t h e ini tial

identified with a silver probe (G). If one has difficulty in iden' . pa ncreatic duct, secretin can be administered in travenou Iy.

ncreatic duct, secretin can be administered in travenou Iy. (F). sph incte rotomy incis ion ,

(F). sph incte rotomy incis ion , the pancrea tic orifice ,.".",-

T he sphincterotomy is extended, generally for 1 to 2 ern, wid! :un.=

is extended, generally for 1 to 2 ern, wid! :un.= sy nt hetic absorbab le s

sy nt hetic absorbab le s ut ures being placed to approximate duodeaal ~~

mu cosa. Fin a lly an apex s ut ure is placed w hen the diameter of the

sphincterotomy

is deemed s uff icient (G).

,.:.;o,~

T he lengt h of the sph in cte ropl asty inc is ion will vary de pendin''J

reason for its performa nce. If one is perform ing a sphincteropla ty IDf':rly

di slodge a n im pacted common du ct stone, a larger incision i

the sphincteroplas ty incision is large enough to di sim pact the

other hand , if one is perform ing a s phin cteroplasty in cision in a ~.,.,

dilated du ct beca use of t he conce rn of leaving behind retained

sphincteroplasty incis ion 2 to 3 cm

carefu l not to extend the sph incte roplasty inci s ion beyo nd the point wt:e::i~Clf biliar y t ract and duodenum have a common wal l. With caref ul appn:lrimtDl, however, of the ducta l and duodenal mucosa, ri sk of retroperi toneal or intrape ritonea l lea kage is virt ually eli minated . If the sph incteroplasty has been carried out for what are believed m

symptoms re lated to the pa ncreas, from a stenotic pancreatic

se p totomy ca n be performed w i th Pott's sc i sso r s ( H ) . This in c i ion can C:'S~~

be extended for 4 or 5 mm, at which point the septum thicken a the<DIUSlem the pancreatic and bili ary tree diverges. Some feel that the pa ncreatic and ductal mu cosa sho uld also be approxima ted with 5- 0 or 6- 0 ynthetic absorbable material.

unnea:5S<!:}"c

lone.

10

0 or 6- 0 ynthetic absorbable material. unnea:5S<!:}"c lone. 10 t~.n a in length may be

t~.n

a

in length may be carried ou t. One

0 or 6- 0 ynthetic absorbable material. unnea:5S<!:}"c lone. 10 t~.n a in length may be

d uct

a

Ampu lla Biliary balloon catheter Pancreatic duct orifice Probe in It------ -- pancreat ic duct
Ampu lla
Biliary
balloon
catheter
Pancreatic
duct orifice
Probe in
It------
--
pancreat ic
duct

F ollowing the compl etion of the

phincteropla ty, the biliary balloon

catheter is removed , the cystic duct the ga llb ladde r is removed from the stump is liga ted wit h a 2-0 s ilk.

is doubly clamped and divided. operative field (I). The cy tic due;

If the sphincteroplasty is being performed because of chola ngiographic ev idence of biliary calcu li in a norm al s ize or small common duct, to avoid the

tech nical and mechanical

choledochotomy, we have utilized tra nsampullary exploration. The common duct ca n be explored wit h t he sa me va riety of in struments as one utilizes with the traditiona l duct exploration t hro ugh a choledochotomy (see pages 10-17).

Bi li ary scoops, Ran dall Stone forc eps (J), flu shing th rough a French catheter

(K), and balloon catheter ma nipulation (L and M) can all be utilized.

problems of exploring a small du ct through a

 

At the end

of

the procedure one does not ha ve to be concerned abou t placin",

a

s mall T -tube

in a s mall common duct. In addi tion, a sphincteroplasty ha

been performed , so if on e does not retrieve all stones in t he biliary tree, the

stones have a free course to pass spontaneously.

Biliary balloon catheter Clamps on cystic duct .:. ~ Ligated~ cystic duct stump i------ Sph
Biliary balloon catheter Clamps on cystic duct .:. ~ Ligated~ cystic duct stump i------ Sph
Biliary balloon catheter Clamps on cystic duct .:. ~ Ligated~ cystic duct stump i------ Sph

Biliary

balloon

catheter

Clamps on

cystic duct

.:.

~
~

Ligated~

cystic duct

stump

i------ Sph i nct e r oplast)

Randall Sto ne lorceps

--.:., Balloon inflated
--.:.,
Balloon
inflated

Ba l loon defl ate d

~L- _
~L-
_

T he lateral stay s utu res are removed from the duodenum, and sut ures of 3- 0 s ilk are placed at each end of the duodenotomy The duodenum is closed in two la yers . The inner layer i

fa y

.

a

continu ous suture of 3-0 sy ntheti c absorbable material placed in a

Connell fashion (0 ). Sutures are started at each end and are tied in the middle.

The outer layer is a row of interrupted 3-0 silk sutures (P). The duodenotomy is drained with Penrose or closed suction drains .

Inner layer 0

duodenolomy

closure

Sphincleroplasty

Ouler layer 01 duodenolomy

closure

Side-to- ide Choledochoduodenostom

Operati e Indications

S ide-to-side

choledochcxlucxlenostom y, like

phincteropla ty, is a

procedure that has been used in the past for a variety of disease processes. It is used much less frequently now than a decade or ago. Side-to- side choledochoduoden ostomy can be u ed for calculus

disease of the biliary tract if after common du ct exploration one i unsure the biliary tree has been cleared of stones. Performing a side-to- ide choledochoduodenostomy wi ll allow any retained stones to pa pontaIlEOns!y.

In the past the most common indication for t his procedure ha

been fur-

primary or recurrent common duct stones. Following choledochotomy and extraction, a side-to-side choledochoduodenostomy has been advocated by""""'" for primary common duct stones, to prevent recurrent stone formation or to allow recurrent stones to pass spontaneously if they do recur. Tcxlay. patients with primary common duct stones are treated by endoscopic papillotomy. Patients with distal biliary strictures are particularly good candida side-to-side choledochoduodenostomy. An individual with chronic pan:cn:ruiUs and a distal biliary stricture secondary to scarring and fibrosis of the hez « the pancreas can often be managed by side-to-s ide choledochcxlucxlenos y. Some surgeons have also advocated its use for palliation of biliary Obs:tructXll from distal malignant disease that is unresectable, particu larly in the case where a cholecystectomy has previously been performed and the galIblarlrl., i not available for biliary decompression. Although there are theoretical objitrlil;;;;; to placing the biliary anastomosis so close to the primary tumor, experience • several centers has demonstrated that this can be an effective way of a - . palliative biliary decompression. Side-to-side choledochoduodenostomy also be an effective operation in patients with recurrent biliary symptom a perivaterian diverticulum. Many have advocated diverticulum resection, side-to-side choledochoduodenostomy is a safer, easier procedure.

Operative Technique

P atients are explored th rough a

right subcostal incision. These

are explored th rough a right subcostal incision. These generally have had a prior cholecystec tomy

generally have had a prior cholecystec tomy , and the old incision - reentered.

Most biliary t ract s urgeons feel that the diameter of the patien

co mmon duct should be at least l liz cm, and preferably 2 cm, before the

oper ation can be performed. If the procedure is being

primary or recurrent common duct stone, the biliary tree i u ually markedly dilated, with a large, often ovoid or cigar- haped brown primary common duct tone lcxlged di tally (A). Complete biliary ob truction is

uncommon in these patient. and the bilirubin i elevated_

The adhl:9:1DS !-.- dh;ded- The

sh.ari> a:IC

performed faT a

u ually only mildly

"

"

OmentUID and the under

urface of the IiYer

extrahepatic biliary tree are exposed via

).

A Cystic duct stump Ampu lla _-' _

A

Cystic

duct

stump

Ampu lla _-' _

A dhesions and attachments between the

hepatic flexure of t he colon

and the duodenum are di vided s harpl y, and the duod enum is

kocherized (C). Medial attachments between the omentum and duodenum are

also divided (D). As much of the duodenum is exposed and mobilized as poss ible, so the duode num can be brough t up on top of t he common duct for a tension-free side- to-side anastomosis.

Kochen:zed _

c:Uxlenu!:J

\
\
----y Head of ~--:'tr-.-------- pancreas
----y
Head of
~--:'tr-.-------- pancreas

T he first portion of the duodenum is dissected off the anteri or surface of the common duct fo r as great a length as poss ible , Once the duode n um has been compl ete lv mobil ized and the extrahepatic

bi lia n ' t ree exposed along its a nte ri or. late r al. and medial surfaces. a

choledoc horomy is performed with the dist al end

the biliar\' t ree passes posteri or to t he fir st

E), Th e cho ledochotom y is ini t iall y made w it h a 15 blad e: it is then extended wit h Pott 's sci ssor s , The length of t h e ch oledoch otomy shou ld be at least 2 em. The diameter of the common duct s hould be a t least 11/2 cm. a nd pr eferably 2

e m, before thi s operation can be perform ed.

choledochotom y has been performed, the du ct is explored and

all calculi are removed (F). Th ese pati ent s generall y \\'i ll ha ve had

preoperative cholangiography performed either percuta neously or

endoscopically. Thu s known at the t ime of

bee n pr ev iousl y de s cribed for common duc t expl ora t ion (se e pages 10- 1, 1are all carried out. Primary common duct s ton es are often bro\\'n , easily crushable, and accompanied by sludge in the biliary tree that is best

removed by irrigation. On ce the biliary t ree ha s been cleared of calculi , a longitudi nal

du odeno to my, th e sam e length as th e in the duod enum directl y adja ce nt to,

exte nding to the point where

port ion of t he duod enum (inset and

Once the

t he exac t number of s tones and the ir location are often s urgery. However, the vario us maneu vers that have

choledochotom y,

is perform ed

but a t right angl es wit h , the

choledochotomy (F). Thi s ana s tomosi s is usuall y performed in one lay er. Al t h oug h

synthetic

absorbable s utures have been

advocated by some bilia ry s urgeons,

we use

3-0 silk , with all knots placed

on th e outside. The apex su t ure in t he

chol edochotoiny is placed fir s t. A 3-0 s ilk is pa ssed fr om ou t s ide the bi liary

tree to within and then passed from

secured (F). After this a pex suture has been placed, la teral st ay s u tures of 3- 0 silk

a re pos it ioned. Thes e pass from out side in a t the mid por t ion of t he choledochotom y and from ins ide out at th e t w o ends of t he duodenoto my.

These s ut ures are then gathered in

holding the t wo ends of t he s ut ure ,

betwee n the

a hemostat as demonst r ated (G , see H),

within th e duodenum to t he out side and

as well as th e mid por t ion t hat passes

d uode num and t he

common duct. Thi s nicely alig ns t he

duodenu m a nd ch oledochotomy fo r su bseq uent sut u re placem ent.

d

d Common duct ~ stone , _ -'-_ Duodenotomy ~ / Apex suture \ Lateral slay
Common duct ~ stone , _ -'-_ Duodenotomy ~ / Apex suture
Common duct
~
stone
,
_ -'-_
Duodenotomy
~
/
Apex suture
d Common duct ~ stone , _ -'-_ Duodenotomy ~ / Apex suture \ Lateral slay

\

d Common duct ~ stone , _ -'-_ Duodenotomy ~ / Apex suture \ Lateral slay

Lateral

slay

suture
suture
I nterrupted su t ures of 3-0 ilk are then placed. alway pa ing from

I

nterrupted su t ures of 3-0 ilk are then placed. alway pa ing from ' in on the common duct ide and from in ide out on the duodenal ide, and cuning each suture as it is placed (H). When this layer has bee n completed ou t to th e ends of the

When this layer has bee n completed ou t to th e ends of the duoden

duoden ot omy and the midlateral aspect s of the chol edoc hotomy. the s utures are secured (1). The anterior row is t hen placed, by pa sing a

firs t fr om outs ide in at the mid portion of th e duodenotomy and then from

inside out at the most proximal portion of the choledochot omy (1). T his suture .

gathered in a similar fashi on by holdi ng bot h ends and the mid portion of the

sutu re in a hemosta t. Again this nicely a lign s the duodenotom y and choledochotomy so that the anastomosis can be completed . The anastomosis is comp leted with a series of th ro ugh-and-through interrupted 3-0 si lk s utures (J).

tay

UMe

row
row

Posterior

row Posterior Posterior row Apex Suture
row Posterior Posterior row Apex Suture
row Posterior Posterior row Apex Suture
Posterior row
Posterior
row
row Posterior Posterior row Apex Suture
Apex Suture
Apex Suture
row Posterior Posterior row Apex Suture

T he final t hree or four sutures of the side·to·s ide

performed by

choledochoduodenostomy are held until all sutures are placed, and then they are secu red (K). This is a sid e·t o· s ide anas tomosis, which is

pulling the first and second portions of t he duodenum

on top of the common duct and then carrying out the anastomosis. Th e anastomosis can easily be palpated through the duodenum when the procedure is completed and should be widely patent (L). The anastomosis is demonstrated diagrammaticall y in M. Th e theoretical shortcoming of the procedure is also nicely depicted. There is a segemen t of

biliary tree that extends from the choledochoduodenostomy down to the ampulla. It has been reported that vegetable material from the duodenum can

pass into the biliary tract through the side·to·side anastomosis and become impacted distally, producing nonspecific right upper quadrant symptoms

referred to as "the sump syndrome." This

operative procedure, but one that is rarely encountered. The biliary tree is

generally

is a theoretical disadvan tage of the

not decompressed with aT - tube.

The area of the choledochoduodenostomy is drained with either Penrose or

closed suction drains.

Completed

Side-ta_side

anastomoSis

Resection of a Bemgn Bile Duct

Stricture With Reconstruction Utilizing Silastic Transhepatic Biliary Stents and Hepaticojejunostomy

Operative Indications

B enign bile duct strictu res can follow a variety of cl inical situations. Scarring and fibrosis of the head of the pancreas in chronic pancreatitis can result in a distal biliary stricture. Rarely, inflammatory disease of the gallbladder can involve the extrahepatic

bil iary tree and result in a stricture. The majority of benign strictures, however ,

a stricture. The majority of benign strictures, howe ver , follow If the stricture involves the
a stricture. The majority of benign strictures, howe ver , follow If the stricture involves the

follow

If the stricture involves the mid or di stal portion of the biliary tree, the repair is straightforward. The proximal biliary segment is dissected, and a mucosa-to-mucosa anastomosis is performed between the common hepatic duct and a Roux-en-Y jejunal loop. Long-term stenting is not necessary, but decompression with aT-tube or a preoperatively placed transhepatic catheter is of benefit for one or two months, during w hich time healing of the hepaticojejunostomy takes place. Many, if not most, extrahepatic injuries that occur during cholecystectomy, however, involve the common hepatic duct proximally, near or even involving the bifurcation. These high strictures are more difficult to manage. In recent years the majority of patients referred to our institution with postcholecystectomy strictures have had multiple ligaclips in the porta hepati s, and these usually are found to be responsible for the stricture (A). It is our practice to perform preoperative percutaneous transhepatic cholangiography on all patients with suspected strictures. At the time of cholangiography, a Ring catheter is inserted. In most instances, if continuity between the proximal and distal biliary tree has not been totally disrupted, the Ring catheter can be passed th rough t he stricture distally into the duodenum. Occasionally it is necessary to decompress the proximal biliary segment

externally for a day or two and then at a second setting pass the catheter distal to the stricture into the duodenum. Identification of the proximal biliary segment and stricture and placement of a trans hepatic Silastic biliary stent, if used, are made much easier at the time of surgery if a Ring catheter is in place.

operative trauma,

usuall y during cholecystectom y.

Operative Techniques

M ost patients with benign biliary st rictures will

have undergone a

cholecy tectomy through a right subcostal incision. Patients are prepped and draped so that the Ring catheter is accessible in the

prepped operative field during the procedure. The abdomen i

reentered through the old right

ubcostal inci ion.

Upon Teen'

e abdomen multiple adhesion

are encountered,

particuJarly IHlltUll the

tu:;;), colon, stomach, duodenum, and the under

surface of the m-a--_ Thse are . both sharply and bluntly (8).

A

"'~-------- SlIlIC1Il"'_<!_ - " ,a
"'~--------
SlIlIC1Il"'_<!_ - "
,a

Cystic duct stump

_ ~\\

B

I
I

Ring

cath eter into

duodenum

Adhes.,ns betlteen liver and omentum
Adhes.,ns
betlteen liver
and omentum

,

CO \\

);

B y palpat ing in the pona hepari

for rhe pre\·iously placed Ring

catheter , iden tifica ri on of t he bili a ry t r ee is greatly fac ilitated.lnrhe

pas t, part Icula rl y If the pat Ient had been opera ted upon several tlffies,

thi s d issect ion ofte n t ook hours . Wi t h t h e cat h et er in pl ace, the

di ssection proceeds rapidl y, and w ithin a relati vely s ho r t tim e t he prox imal

biliary segm ent ca n be identified. On ce th e extrah epa ti c biliary tract ha s been identifi ed , it is cl eaned and mobilized, and then it is e nc ircled with a vessel loop (C). Di s sec t ion then

proceeds proximally up toward s the bifurcation. Th e proxima l bili ar y segment

is frequently s urrounded by a

Multipl e ligaclips ofte n add to

tree identified a nd encircled, it can be retracted a nd th e por ta l vein and hepatic

arter y exposed. When one a pproac hes common hepatic du ct th at a ppears reason ab ly normal , the a nte r ior wa ll of th e du ct is opened (D) a nd t he Ring cat heter

ex tra cted (E). Occas ionall y biliary ca lculi and s ludge thi s is removed via bilia r y scoops a nd w ith

dense inflammatory reacti on wit h fibros is. th e diffi cult y of th e di ssec ti on . Wi t h the bili ary

w ill fo rm above the benign strict ure; irrigation (F).

Strictured common duc~ (con ta ining Ring catheter) f Openmg normal coovnon hepatic duct Ring
Strictured common duc~ (con ta ining Ring catheter) f Openmg normal coovnon hepatic duct Ring

Strictured common duc~ (con ta ining Ring catheter)

f

Openmg normal

coovnon hepatic duct
coovnon
hepatic duct
Ring catheter _ I
Ring catheter _
I
Sl udge and sma ll stones
Sl udge
and
sma ll
stones

O nce all the calc ulus ma te rial ha s been removed, stay

placed in t he proximal biliary segment, and t he

common hepa t ic duct is di vided (G).

utu res are

back wall of the

The distal st ri ctu red port ion of the biliary tree is dissected free

down to t he point whe re t he common du ct passes posteri or to the duodenu m

(H). At th removed

is point the duct is di vid ed and the strictured ext rah epatic biliary [ract

from the ope ra tive field.

The di s tal biliary tree is closed with a seri es of interrupted 3- 0 silk

utures,

in th is in sta nce placed in a verti cal mattress fashion (I).

The cur ved end of th e

Ring catheter is amp utated. The Ring cathete r ,

whi ch has previou sly been prep ped an d draped in the operat ive field, is t hen

pull ed

t hrough t he chest wa ll in to the periton ea l cav ity to ex pose it s entr y site

on the

diaphragmat ic surface of the li ver (J).

of common hepatic duct , I
of common
hepatic
duct
,
I

)

of common hepatic duct , I ) Common duel closure IrJ Ring catheter 43
of common hepatic duct , I ) Common duel closure IrJ Ring catheter 43
of common hepatic duct , I ) Common duel closure IrJ Ring catheter 43

Common duel

closure

of common hepatic duct , I ) Common duel closure IrJ Ring catheter 43

IrJ

of common hepatic duct , I ) Common duel closure IrJ Ring catheter 43

Ring

catheter

A thi point the urgeon prepares to replace the Ring came fT ;i-" a

transhepatic ilastic biliary tent. In order to avoid losing rhe tra I

t

a catheter should break or become dislodged during the

fT. a

guidew ir e is placed t hr ough the Ring cathete r. Utilizing a ;: 12 Co

c

cathete r wit h Ring ca t heter

pu ll ed out th rough t he s uperi or s ur fa ce of the li ver , the r eby po itioning the Coude ca t heter in the right hepa t ic duct (K).

The Ring catheter is removed , the transhepatic biliary sten t (# 16 French )

Coude catheter (L). By w ithdrawing t he Coude ca t hete r ou t the top of rhe \~. the Silastic tran s hepatic biliary s ten t is plac ed in t he a pp rop r iate position i "- right and common hepatic ducts.

t he tip cut off , t he ca t hete r is placed over the guidewire on lO a nd sut ured in place wit h 2- 0 s ilk . T he Ring catheter is then

guidewire is s utured

is adva nced , and a

it

·c

into t he flanged end of the

K ,r-- -- Ring catheter ,-'---_ _ Guidewi re / 1+--- - - Coude caIhe!er
K
,r-- -- Ring catheter
,-'---_
_
Guidewi re
/
1+--- -
-
Coude caIhe!er
Ring catheter ,-'---_ _ Guidewi re / 1+--- - - Coude caIhe!er • f( +- _

f(

+-

_

S . 1as!Jc biliaty sIerI

GUIdewwe

I

a Ring catheter has not been placed preoperati\'ely, other techniqu

are

utilized to place th e

bilia ry segmen t

tree can be inst r ume n t ed w it h a Ra nd a ll Stone force ps passed u p to within

Si last ic tra ns hepat ic biliary ste nt. After the proximal

has been dissected an d t he stric ture resected , the biliary

1

or 2 c m of Gli sson' s

caps u le. Th e clamp is th e n fo r ced out t hrough Gli son'

caps ul e an d a S ilas ti c s ten t s ut u red to it (M). By w it hdra w ing t he Ra ndall

forceps,

An a ltern ative is to intrahepat ic bil ia r y t ree

a nd th en to s u t ure th e Si las t ic ste n t to the oli ve tip. A hol e d ri ll ed in the olive t ip aids in securing t he s tent to the in st rum en t. By whatever means, once the transhepatic Silastic biliary stent ha been

placed , it is pos itioned so that the portion of th e s tent wit h mul tiple

con ta in ed w it hin t he li ver a nd in that por t ion w hich is to be pl aced in the Roux-

en ·Y loop (N). Th e part of the sten t th at emana tes from t he li ver obviou sly con ta in s no s ide holes .

tone

t he S ilast ic s t en t is pl ac ed.

pass a n a nd out

elongated Bakes dil ator up t hrough th rough th e s uperior s urfa ce of the

the

liver (i

ide hoI

j-

t he s u perior

urface of

On e can place a mattress s ut u re around th e egress s ite of the sient on the

s u per ior s u rface of t he li ve r have fo und tha t t his s u ture

out t hroug h t he s up er ior s urface of t he li ve r a roun d t he ste n t is un u ual.

w it h a 1-0 s ynt heti c a bso rba bl e s ut u re. Recently is not absolu tely necessar y a nd t ha t bili ary leakage

-e

1;/ '1 ' /
1;/
'1
'
/

Bakes

dilator

&lashc

botiary

slent

Side holes ·

.I

In

S rastic bili stent ary

Mattress suture
Mattress
suture

A Roux. en.y jejunal loop 60 cm in length is con st ructed. A proximal loop of jejunum, just di sta l to the liga ment of Tr eitz, is di vided betw een

intestinal clamps at

a con veni ent arcade. Thi s can al so be

perform ed

con veniently wi th a GIA st apler. Th e small bowel mese nte ry is

divided down towards the root. The Roux·en·Y loop is brought in to the righ t upper quadran t in a retrocoli c pos ition, through the t ransve rse mesoco lon directl y on top of t he secon d an d third portions of the duodenum (0 ).

Q
Q
, Ligam ent of Treilz
,
Ligam ent
of Treilz
_ --,"_ Transverse colon Midd le COI IO-_ = ;'" vessels
_ --,"_
Transverse
colon
Midd le COI IO-_ =
;'"
vessels
Duoden,um
Duoden,um
Distal jejunum 1 I I I Slone clamps
Distal
jejunum
1
I
I
I
Slone
clamps
Transverse colon Midd le COI IO-_ = ;'" vessels Duoden,um Distal jejunum 1 I I I

,

Transverse colon Midd le COI IO-_ = ;'" vessels Duoden,um Distal jejunum 1 I I I

E nteric co nt inu ity is reesta bli s hed with an end-to-side jejunojejunos to my. Thi s is performed 60 cm di sta l to the end of th e Roux-en-Y loop. The end-to-s ide anastomos is is ca rri ed out with an oute r

inte rrupted layer of 3- 0 silk and an inn er continuous layer

abso rbab le placed, t he

material. After t he poste ri or row of interrupt ed

of 3- 0 sy nth et ic s utu res has been

end of the proximal jejunum in t he in testi nal clamp is removed with

the electrocautery (P). An entero tomy is mad e a long the ant imesenteric border in the Roux loop at

layer is ca rri ed out

the point of th e end -to-side

with 3-0 sy nth eti c ab sorba bl e ma teria l placed in a continu ous ove r- and -ove r

locking fas hion (Q). This suture is conti nued as the inner anterior layer and is

stitc h (R).

placed using a conti nu ous Conn ell

anastomosis. The pos ter ior inn er

The outer anter ior laye r is comple ted with interrup ted 3-0 silk s utures (S).

The defect in the small bowel mesentery is closed wit h in terrupted 4- 0 silk

sutures, as pictured here, or with a cont inu ous 4-0 sut ure (T ).

The end of t he jejunal Roux loop is closed in a similar

fash ion , with an

inner co ntinuou s layer of 3-0 sy nt heti c a bsorbable material placed in a Con nell

fashio n and an outer in te rrup ted la yer of 3-0 silk.

s

p

s p Outer layer of postenor row of end -to-side jejunojejunostomy Proximal jejunum Enterotomy Inner layer

Outer layer of postenor row of end -to-side jejunojejunostomy

Proximal

jejunum

Enterotomy
Enterotomy

Inner layer of

posterior row

, -

Inner layer of anterior row / ~/ / /~~.'/ , Outer layer of / /
Inner layer of
anterior row
/
~/
/ /~~.'/
,
Outer layer of
/
/
/.
anterior row

/

Closure of

mesente ry

T he Roux-en-Y loop is brought into the right upper quadrant in a retrocolic fashion th rough the root of the trans verse mesocolon, on to p of the second and th ird port ions of the duodenum. If the two end silk sutures of the outer layer closure are left long, these aid in

positioning of t he loop (U). If the loop is 60 cm in length and the division in the small bowel mesentery is long enough, the Roux-en-Y loop will comfortably rest in the right uppe r quad rant wi thout tens ion ('f) .

_ _ Middle co lic vesse ls Hepatic duct bifurcation -en-Y Duodenum v Silastic biliary
_ _ Middle co lic vesse ls Hepatic duct bifurcation -en-Y Duodenum v Silastic biliary
_
_
Middle
co lic vesse ls
Hepatic duct
bifurcation
-en-Y
Duodenum
v
Silastic
biliary
stent
"-
Port al v.
r- -
-
-
-- -
Common he pat ic a.
- ---,O;€I---
-
-
Raux - en - Y
jejunal loop

T he hepaticojejunostomy i performed in one Iayer_ me > n:; perform thi ana omosi in two lay , usin a :anery _ u·ure materiaL In thi e.xample we will demonstrate a one-layer

ana tomosis with mterrupted 4-0

ynthetic absorbable material tba

ha proven to be entirely satisfactory . Th e poste ri or row is placed fi r st between the proxima l biliary egment and the Roux -en -Y jeju nal loop, prior to performing an enterotomy and X'). The sutures pass in to t he submucosa l la yer of the jejunum and then through and th rough the proximal bi liary segment. Th e proxim al biliary segment often i no a complete rim of good mucosa, especially if t he pa tient has had attempt at prior repairs . This is the principle reason for using a tran shepa ic ilastic biliary s tent and leavi ng it in for a prolonged period during healing and wound contracture.

has been pos itioned, the s utures are all secured, and

an enterotomy is performed with the electrocau tery \f). The sutures are divided

and t he Silastic tran s hepatic biliary ste n t is placed through

the Roux-en-Y loop (l ). The anterior row of the ana stomosis is compl eted with a single layer of

Once the pos terior row

the enterotom y into

interrupted t hrough-and-through 4-0 sy nthetic absorbable sutures (M

). Thi

anastomos is is no t strictly s pea king a mucosa -to-mucosa anastom os is,

because

the posterior row wa s placed before t he enteroto my. Howe ver it fun ction a a mucosa-to-mucosa anastomosi s and is eas ier to perfo rm than if an enterotomy i

made first (BB).

,/ ,/ 1 x Poster ior row of hepaticojelunostomy Sliasbc bi liary stent Completed anastomosis
,/ ,/ 1
,/
,/
1

x

,/ ,/ 1 x Poster ior row of hepaticojelunostomy Sliasbc bi liary stent Completed anastomosis ~

Poster ior row of

hepaticojelunostomy

,/ ,/ 1 x Poster ior row of hepaticojelunostomy Sliasbc bi liary stent Completed anastomosis ~
,/ ,/ 1 x Poster ior row of hepaticojelunostomy Sliasbc bi liary stent Completed anastomosis ~

Sliasbc

bi liary

stent

Completed anastomosis ~ =--
Completed
anastomosis
~ =--
Enterotomy rowol _
Enterotomy
rowol
_

in

. r., " tio:ojejunostomy

~~ ----~ -----­

T he Roux-en ·Y loop is tacked to periportal material on the uode.

.

.

surface of the liver to insure that there i

no ten ion on the

anastomosis . The Roux·en ·Y loop is also tacked to the opening in the trans verse mesocolon, to prevent small bowel herniation (CC).

The end of the Silastic biliary sten t that emanates from the uperior surface of the li ve r is brought out through a stab wound in the ri ght upper quad rant. It is sutured in place at the skin using 5- 0 sta inless steel wi re. It is

placed

ite of the

transhepatic biliary stent. It is brought ou t through a stab wound in the right upper quadrant. The hepaticojejunostomy is drained with either Penrose or

closed suction drains. At five days cholangiography is performed t hrough the Silas tic stent. and if no leaks are ev ident at the anastomosis or at the s uper ior surface of the live

t he s te n t is clamped . Th is can be accompli s hed by

stopcock on the end or a heparin lock. The patient is taught to irrigate the tube t hree t imes a day wit h a 20 ml of saline . T he stent is left in for a 12-month period to allow wound healing and

contractu re to proceed, in the face of a wa lled S il ast ic stent. Eve n tho ug h the

relat ively nonreac t ive, bi li ary sludge can co ll ect and occlude s ide

reason t he stents are changed every three or four mon t hs as an outpatiem procedure. Un der fluoroscopy a guidew ire is placed in to the Roux·en·Y loop through the lu men of the old stent. The old stent is removed and a new one

eas il y sli pped in pl ace. At th e e nd of one year th e ste nt can be rem oved with

virtua l cer tain ty segme nt a nd the

indefi ni te ly. If t he benign stricture involves the hepatic duct bifurcation, it is nee

to resect t he bifurcation a nd to perform bilateral hepaticoj eju nostomies.

Preoperat ively Ring catheters shou ld be pl aced in both the rig ht

duct s . Follow ing bifurcation resection , Silastic sten ts are pla ced in both the right and left hepatic ducts and bilateral hepaticojejun ostom ies perfor med in the manner just demonstrated.

biliary stents are made of Silas tic and are

to bil e bag gravity drainage.

A Silastic sump drain is left near t he top of the li ver at the egress

eit her placing a three·way

re latively nonreact ive large bore, thick·

holes . For thi

that a sta ble jeju num has

a nastomos is between t he proximal biliary been created th a t will function obstruction ·free

ary

and left hepatic

cc Hepat.cote u'o.5IOI_ Sllasbc bi ary stent In Jejunum
cc
Hepat.cote u'o.5IOI_
Sllasbc bi ary
stent In
Jejunum
-' I ( Transverse colon \ ~ End-Io-side jejunojeJmoslcmy /
-' I
(
Transverse colon
\
~
End-Io-side
jejunojeJmoslcmy
/

of a Proximal

K€~ection

olangiocarcinoma

Ith

Reconstruction Utilizing Silastic Transhepatic Biliary Stents and Bilateral Hepaticojejunostomies

Biliary Stents and Bilateral Hepaticojejunostomies R "9 catheters / • Operati ve Indications W h t

R "9 catheters

/

and Bilateral Hepaticojejunostomies R "9 catheters / • Operati ve Indications W h t he frequ

Operative Indications

W h t he frequ ent use of end osco pi c a nd percutan eou

it

s mall neo plas ms, re fe r red to as Kl a t s kin tumors, ar e

chol angiograp hy ove r th e past decade , an increasing nu mber m pa t ient s with prox imal biliar y t um ors have been iden tified.11Je;e

mall

ad enoca rcin oma s t hat a re nea r or in vo lve th e

an y indi vidua l prese nting with jaundice, who on CT sca n or sonography is

found to have dilated intrah epati c du cts t ree and ga llb ladd er, is highl y s us pec ted cholangi oca rcin oma.

We fee l t ha t with inse rt ion of

th e tum or , a nd di st all y in to th e d uodenum. In

pa tient s can ha ve t hese cath eters placed bil ate ra ll y through the

th e du odenum ,

hepat ic du ct bifurcati on. Today

with a collapsed ex trahepatic biliary of ha ving a prox im a l

s uch pat ient s s hould und ergo percutan eo us cholangiography.

Rin g catheters into th e ri ght

and left hepati c ducts, througlt

ou r ex peri ence vir tually

al l

des pite t he initial cholangiogram de mons trating

tumor and into complete

obst ru ct ion at th e bi fur ca t ion, Pati en ts wit h prox imal chola ngioca rcin oma are

staged preoperat ive ly with cholang iogra ph y and ang iog raph

chola ngiogra ph y tu mor clea rl y ex tend s up into th e hepat ic parenchyma of both lobes, t he pati ents a rc pa lli ated with th e I~ing ca th eters and not explored. In addit.ion, if angiograph y demon s trates encaseme nt of th e co mm on hepatic artery

or main portal ve in , pa ti cn ts ar e fcltt o be unresec tabl e a nd are not explored .

Howeve r , if onl y on c bra nch tum or exten ds in to on ly one

lobecto my is ad ded . Afte r preoperat ive s taging , approxim ately 80 percent of pa ticnts prese n t ing with cholan gioca rcin omas are cand idates for resecti on.

Operative Technique

y. If on

of the hepat ic ar te ry or porta l vein is in volved or lobe, pa tie nt s may s till be resecla bl e if hepatic

P at ients are prepped a nd draped so that the s urgeon ha

tumo r disseminat.ion. In our

access to both

used

Ring cat heters in t he oper ati ve fi eld. A ri ght s ubcostal incision i

Atth c time of laparotomy th e abdomcn is expl ored for evidence of

ex perience li\'e r metas tases or peritoneal lymph nod e in volveme nt is u n u ual.lf a

Implant s ar e un co mmo n. In addit ion.

patient is unresecta bl e. it ge nera ll y is becau se of loca l in volve men t of

pa renchyma of both the right and left lobes or involve ment of the common hepat ic artery or main portal ve in . At the time of laparoto my initiall y t he t um or us ually cannot be vi lIalired or even palpated. The gallbladder and extrahepatic biliary tfee appear nonna.I (A). HoweYeI'. if one palpates high in the hilum of the liver. by feeling for the diveJgt1Itt mthe Ring catheters. the area of the bifurcation and tuInm' can be

identified

A B Tumor \ invoMlg hepalicdld bifurcalion Gall bladder ----- --t-'+ Hepatic fl exure of
A B Tumor \ invoMlg hepalicdld bifurcalion Gall bladder ----- --t-'+ Hepatic fl exure of

A

B

Tumor \ invoMlg hepalicdld bifurcalion Gall bladder ----- --t-'+ Hepatic fl exure of co lon
Tumor
\
invoMlg
hepalicdld
bifurcalion
Gall bladder ----- --t-'+
Hepatic
fl exure
of co lon
A B Tumor \ invoMlg hepalicdld bifurcalion Gall bladder ----- --t-'+ Hepatic fl exure of co

Duodenum

T WO maneuver greatly aid in exposure and di

identified, doubly clamped, divid ed,

(C). This greatl y

ection of the hepatic

duct bifurcation. The first is mobilization of the gallbladder. If the

gallb ladder has not been rem oved previously, the cy tic artery i

and ligated, and the gallbladder i- improves acce to the

mobilized out of the li ver bed

bifurcation. In addition early in the dissection of the porta hepati , the di tal ext ra hepat ic bil iary tree is dissected and looped with a vess el loop (C). Identi fica ti on and di ssec tion of the common duct is facili tated by having the Ring catheters in place, particularly if the patient ha s been operated upon

previously. Once the di s tal common duct has been mobili zed, the ant erior wall i opened and the Ring catheters extracted (D). The duct is then completely di vided. The dis tal com mon duct ca n eit her be ligated or closed with inrerruprro

3-0 silk sutures placed

These t wo man euve rs, mobili zatio n of the gallb ladder and early divi ion of die di s tal common duct, greatly aid in access to and di ssect ion of the bifurcation.

in a verti ca l mattress fashion, as demonst rated here

GaWb" - , fossa "If.:--:;-- - -- Mobi lize d gallbladder / - -.~ ,
GaWb" - ,
fossa
"If.:--:;--
-
--
Mobi lize d
gallbladder
/ -
-.~
, I'
!
Tumor involving
hepatic duct
Common
bifurcation
duct
Duodenum ~ _
Duodenum
~ _

;, - --- CJvip." "on ?II

Common bifurcation duct Duodenum ~ _ ;, - --- CJvip." "on ?II ~i>:;:~5t----- - Distal common

~i>:;:~5t----- - Distal common duct

Common bifurcation duct Duodenum ~ _ ;, - --- CJvip." "on ?II ~i>:;:~5t----- - Distal common

E arl y division of the common duct allows one to di ssect the bifurcation

both anteriorly and posteriorly as the proximal biliary segment is

being retracted in a cephalad direction (F). Retraction is aided by

having t he Ring

catheters in place. The bifurcation of the biliary tree

and the tumor rest on the bifurcation of the portal vein and hepatic artery. Dissection of this area without dividing the distal biliary tree, thus allowing retraction of the proxi mal biliary segment in a cephalad direction , is not only difficult, but also hazardous. As the bifurcation is dissected both posteriorly and anterio rl y, t he right and

left hepatic ducts are identified and dissected and are looped with vessel loops

(G). There often is no visible tumor

bifurcation, thicken ing and firmne ss are eas ily identified. One palpates for the Ring catheters above the bifurcation and above tumor

through normal right and left hepatic ducts. The right and left hepatic ducts

are divided, the Ring catheters are ext racted,

removed (H). The distal common duct margin, as well as the right a nd left hepatic ducts,

are marked with different color sutures to aid the pat hologist in checking

microscopic margin s (inset). Generall y frozen section margin s are not sent; these have not proven to be accurate. Often , even w ith the entire specimen, on perma nent section s, t he exten t of the tumor is diffi cult to delineate.

mass . However, by palpating the

and the specimen can then be

the

F

Mobilized gallbladder Oversewn --:_ common duct
Mobilized
gallbladder
Oversewn
--:_
common
duct

J

l ~~~~~,: ""'-1~f-- Porta l v. bifurcation R. hepalic duel i!ii;;;~~-=:::::~- R. and I. hepatic
l
~~~~~,: ""'-1~f-- Porta l v. bifurcation
R. hepalic duel
i!ii;;;~~-=:::::~- R. and I.
hepatic aa.
Duodenum _
I
Bi furcation of
r. hepatic duct
/
,
: /
.I
Tumor
R. hepat ic duct
Specimen
L hepatic dud
Commooducl

B oth the right and left hepatic ducts are intubated with Silastic

transhepatic biliary sten ts . The Ring cath ete rs that were placed

preoperatively are brought in through the chest wa ll in to the

abdominal cavity. In order not to lose the tract if one of the catheters

shou ld break or become dislodged, ca rdiac gu idewires are placed through the Ring catheters. A #12 Coude catheter , with t he tip excised, is then passed over the guidewire and Ring catheter and sutured in place (I). By with drawing the Ring catheters, the righ t a nd left hepatic ducts are in tuba ted with the Coude catheters. T he Si lastic trans hepatic biliary stents (#16 French) are the n placed over the guidewires into the fl a nges of the Coude cathete rs. By withd rawing the Coude catheters, the transhepatic biliary stents are appropriately positioned. The portion of the sten ts that extend outs ide the porta hepatis or reside in the liver contain multiple side holes, while the portion of the stent t hat emanates out through the top of the liver contains no side holes . Hori zontal mattress sutures of #1 sy nt hetic absorbabl e materi al can be placed around the egress s ite of the stent on the superior surface of the liver (J).

Guidewire

(

eoude

cath eters

Mattress suture

 

Silastic

,, _---,-_

biliary

stent

t \, I~I

O ften the point of division of the right hepati c duct is close to the

brough t into the righ t u pper quadran t via a

bifurcation of the anterior and posterior segments. If this i? the case,

the spur is divided and one anastomosis is performed (K). A Roux·en-

Y loop 60 cm in length is then co nstructed, as demo nstrated on pages

48- 53. Th e Roux-en -Y loop is

retroco lic route, on top of the second and third por tions of the duoden um . The anasto mosis is performed in one layer, using interrupted 4- 0 synt hetic absorbable sut ures . The entire back row is placed prior to securing any of the sutures. Each suture passes first through the jejunal loop and then through the duct from outs ide in (inset). Thu s t he knots of t he posterior row wi ll be placed on the ins ide. However, since we utilize synthetic absorbable ma te ri al, thi s is of

no long-term concern. Each su ture is individually placed on a hemostat, and the hemostats are placed in order on a long clamp (L).

i".;:---- Hepatic a. / Portal v. \ \ \ I
i".;:---- Hepatic a.
/
Portal v.
\
\
\
I

O the posterior row of eac h hepaticojejunostom y ha s been placed,

nce

the sutures are sec ured. Bilateral enterotomies are made adjacent to

the posterior row of sutures using the electrocau te ry (M).

The posterior row of sutures, except for the two end sutu res, are

the n divided, and the en terotomy (N). Each

the anterior layer of both hepaticojejunostomies, before securing the sutu res (0 ).

These sutures are simple sutures placed through and through the jejun um and then through and t hrough the duct (inset). Once all sutures of the ante rior row of both hepaticoj ejunostomies ha ve been placed, they are tied .

Silastic stents are placed in the Roux-en-Y loop via each

interrup ted 4-0 sy nthetic absorbabl e suture is

placed for

o

Roux -en -Y

I"I'lllalioop

O nce the anterior rows of both hepaticojejunostomies have been

undersurface of the li ver with interrupted 3-0 si lks to insure

there is no tension on the anastomosis. The Roux-en-Y loop is

secu red, the sutures are cut. The Roux-en-Y loop is tacked to the

that

sutured to the rent in the t ra nsverse mesocolon with int errupted 4- 0 silks to

preven t

Each Silastic transhepatic biliary stent is brought out th rough a stab wound in the right or left upper quadrant, and is sutu red to the sk in with 5-0

are connected to all ow bil e bag drainage t hro ugh

gravity. Th e egress s ite of each stent on the superior su rface of the live r is dra ined w ith a Silastic sump brought out through separate stab wou nds in the right and left upper quadrants. The bilateral hepaticojejunostomies are drained with Penrose or closed

suction drains brought out th rough a stab wound

stents are left to gravity drainage for five days, at which time cholangiography

is performed. If the re are no leaks from the superior s urface of the li ver or at the anastomosis, the t ubes are internalized by placing t hree-way stopcocks or

heparin locks on the ends of the catheters.

irrigate t he stents three tim es a day with 20 ml of saline . We routinely deliver 5,000 rad of external beam radiother apy to t he area of the tumor bed postoperatively. When th is has been completed as an out patient procedure, the patient is readmitted and iridium 192 seeds are lowered down through t he bil ateral tran s hepatic biliary stents and left in place for approximately 48 hours, to boost the radiation dosage an additional 2,000 rad

loca lly. T he iridiu m seeds are then rem oved . Th e transhepatic S ilastic biliary stents are left in permanently. The s ten ts are changed every three or four months as an outpat ient procedure. Thi s is carried out under fluoroscopy by placing a gu idewire down

through the old stent into th e

leaving the guidewire in place. A new stent is eas il y sl ipped in place over t he

guidewire and then the guidewire removed.

herni ation of small bowel (P).

stainless steel wire. The stents

in

the mid abdomen. Th e

The patients are then taug ht to

Roux-en ·Y loop . The old stent is

then removed,

The sten ts a re

left in place perman ently because even though substant ia l

prolongation of s ur vival is ach ieved with this operative procedure , most patien ts

a re not cured an d event ually loca l tumor will recur. If t he Sil as tic ste nts are not

in place, biliary obst ruction w ill result. It is our fee li ng t hat

prolonged by ha ving the most liver parenchyma drained for the longest period of

time. We fee l t hi s are well tolerated

s urvival is

is ach ieved by patien ts

by leaving t he sten ts in perman ently. The stents and require minimal ca re.

p

- - - "'t-~ -4+~-- - Roux-en-Y jej unal loop Hepaticojejunostomies = = '-:-:-=-= =-"::"_
-
- - "'t-~ -4+~-- - Roux-en-Y
jej unal loop
Hepaticojejunostomies
= = '-:-:-=-= =-"::"_ ':::"~ =_ ---=-_Transverse me$ocolon
tacked to jejunal loop
'N
I.-_
_
End-to-side
jejunojejunostomy

-- --- bEry

-

Resection of a Proximal Cholangiocar:cinoma With Hepatic Lobectomy and Reconstruction Utilizing a Silastic Transhepatic

Resection of a Proximal Cholangiocar:cinoma With Hepatic Lobectomy and Reconstruction Utilizing a Silastic Transhepatic Biliary Stent and Hepaticojejunostomy

I·.
I·.

,/ /,

Operative Indications

O ccasionally patients with proxima l cholangi ocarcinoma will e tumor extension onl y up in to one lobe or the other (A). In add! - ~

is not infrequent in such in s tances to ha ve one bra nch

of the

r.2

vein or one branch of the hepatic artery encased or occluded

_ tumor. S uch patients may still be resectable, if hepa tic lobectomy is added ~a exti rpation of the bifurcation and extrahepatic biliary t re e. One i aware . - -,1, poss ibility prior to laparotomy becau se of preoperati ve cholangiographica::lc angiographic findings.

Operative Technique

T he patient is explored through a right subcostal incision, often , extended up to the xiphoid in th e midlin e or over to the left of ri.ll:

abdomen as a left s ubcostal extension. It is particularly importam

that these patients preoperatively have Ring ca theters

in serted bilaterally. The initial operative procedure is as described for the resection of a proxim a l cholangiocarcinom a without hepatic lobectomy. The gallbladder is mobilized to im prove exposure of the bifurcat ion (B), and t he distal common du ct is divided so t hat t he proxim a l biliary segmen t can be reflected in a cephalad direction (C) to facilitate bifurcation di ssection.

li \.~\-.,,~ r . , "' ~) Gallbladder fossa Cystic a. and duct Mobilized -,
li
\.~\-.,,~
r
.
, "'
~)
Gallbladder
fossa
Cystic a.
and duct
Mobilized
-, ,L-
gallbladder
Duodenum
---:-_
-- - ""----- Ring
catheters
O Llaix:hotomy

R i ng caIheIeIs

Proximal , L _ common duct - - -- - - -1~
Proximal
,
L
_
common duct
-
-
-- -
- -1~

duct

L hepa:!ic

R

hepaoc aa.

and I.

Portal v.

Oversewn distal

common duct

, L _ common duct - - -- - - -1~ duct L hepa:!ic R hepaoc

O nce the hepatic du ct bifurcation has been mobi li zed and dissected off

the bifurcation of the portal vein and the hepa tic artery, it is seen

that tumor extends well up in to the left lobe of the liver , probably

also involving the left branch of

the hepati c artery a nd portal vein

(D). On the right, however, norma l duct can be identified by palpating the Ring

catheter above tumor at the bifurcat ion.

the Ring catheter exposed and extracted (D). The left branch of the hepatic artery is identified, dissected, doub ly ligated, and divided (E). The left bran ch of the portal vein is dissected free an d doubly

clamped with s traight Cooley clamps; the branch is t hen divid ed a nd the proximal end oversewn with a cont inu ous 5- 0 synthetic non absorbable s ut u re (F). The distal end up towards the left lobe of the liver can also be oversew n with a continu ous 5-0 su tur e, or it ca n merely be ligated if length permits.

The right hepatic duct is divided a nd

I

~

\ J

~,L-- - .- -tlI\ L .\
~,L-- -
.- -tlI\
L
.\

Common dud

hepa -ca

Ring catheter

""- -'-'-_ Distal common
""-
-'-'-_
Distal common

R. hepatic

duel

L. hepatic duct

duct

Divided

r. hepatic

duct

Portal v. bifurcation

_ R. and L hepatic aa.

hepatic duct Portal v. bifurcation _ R. and L hepatic aa. !Il ~ _ _ i-

!Il

~ _ _ i- -- - - -
~
_
_
i- -- -
-
-

E

Tumor exte ndi ng along

L hepatic duct

Div ided L hepat ic a.

L branch of po rt al v. divided

T he left lobe of the liver is mobilized by dividing the triangular and falciform ligaments (G). The hepatic veins are identified, and the left hepatic vein is dissected free (H).

The left hepatic vein is doubly clamped with acutely curved Cooley clamps, divided, and each end oversewn with a continous 5- 0 synthetic nonabsorbable suture (I). The left lobe of the liver has now been completely devascularized.

G

FalcLUi L.lobe Suprahepatic of liver inferior
FalcLUi
L.lobe
Suprahepatic
of liver
inferior

vena cava

Stomach

-- - ---- 11 ~ ----- - ----_ L. hepatic v. Divided I. hepatic v.
-- -
----
11
~ ----- - ----_ L. hepatic v.
Divided
I. hepatic v.

Spleen

OIapIvagm -

A variety of techniques are available for going through hepatic

parenchyma. In this example, parallel rows of #1 chromic catgut

sutures are placed in a mattress fashion approximately 1 cm on either

side of the plane that is to be divided between the right and left

hepatic lobes. This plane generally extends from the gallbladder fossa to the hepatic veins as they enter the inferior vena cava. The liver parenchyma sutures should be snugged down to compress liver but not so tight as to cut through or necrose liver. The line of division is first marked with electrocautery (J). Generally two or three sutures are placed on each side (K ), and then the hepatic parenchyma is divided with the electrocautery (L). Two or three more sutures are then placed and more parenchyma divided with the cautery. This is perhaps the most bloodless way of dividing hepatic parenchyma; generally the entire liver can be transected with virtually no blood loss (M). The catgut is wedged on large liver needles that can be controlled better if most of their curve is straightened. Other me thods for dividing hepatic parenchyma, including using the Cavitron, will be demonstrated in other procedures.

J

f ) \ Dividing parenchyma
f
)
\
Dividing
parenchyma

Divided I. he pat ic v.

Devascu larized I. lobe
Devascu larized
I. lobe

M

W hen division of the parenchyma has been completed, the specimen is removed from the operative field. The entire extrahepatic biliary tree including the bifurcation has been resected, along with the left lobe of the liver (inset). The tumor invol ves the bifurcation

and clearly extends up into left hepatic parenchyma. Hemostasis is completed on the resected raw area remaining on the right lobe of the liver using both the

electrocautery and figure-of-eight sutures of 3-0 synthetic absorbable material. Because the stay sutures are compressing hepatic parenchyma, very little hemostasis is generally required (N).

Specimen L hepatic v. Tumor extend ing in to I. lobe _ _ _ _
Specimen
L hepatic v.
Tumor extend ing
in to I. lobe _
_
_
_
_
of live r
Ring
catheter
'- L. hepati c a.
_
'---- L. bran ch of porta l v.
./
1----- '--- Liver sutures _ 4 -"--- - '1"1-1--- - Ca udate lo be R.
1-----
'---
Liver sutures
_
4 -"--- -
'1"1-1--- -
Ca udate lo be
R. he patic du c t
Oversewn
I. bra nch
of portal v.
::~ ~ ~ ~~~~=--
R.
"- _
_
_
_
-,,-_
_
_
R.
I.
Duodenum

O ver sewn l. he pa ti c v.

Middle hepatic v.

Resected surface of liver

he pa ti c v. Middle hepatic v. Resected surface of liver b r a nch

b r a nch of p o rt a l v. he pat ic a.

hepati c a.

~S ~~:-J~t'l 0ve,,;e"1n distal co mmon duct

U tilizing the preoperatively placed Ring catheter, a Silastic

transhepatic biliary stent is placed. A guidewire is inserted through the Ring catheter, and then a #12 Coude catheter with the tip excised is placed over the guidewire and sutured to t he Ring catheter. The

Ring catheter is then withdrawn from the top of the li ver,

Coude cathete r. A #16 Silastic transhepatic biliary ste n t is t he n placed over the gu idewire and sutured to the Coude catheter. The Coude catheter is withdrawn, t hereby placing the Si lastic trans hepatic biliary stent (0 ). A Roux-en-Y loop 60 em in length is constructed, as previously demonstrated on pages 48-53. It is brought up into the right upper quad rant in a retrocolic fas hion on top of the du odenum. A hepticojejunostomy is performed using one layer of interrupted 4-0 synthetic absorbable sut ure. The techn ique of this anastomosis was demonstrated in the prior procedure (see pages 66-69). A horizontal mattress s uture has not been placed a round t he egress site of the Silas tic stent on the s uperior surface of the li ver. This is optional. Some

surgeons feel that bile leakage is made less likely by s uch a sut ure; bile lea kage,

however, is rare, as long as the surface of the li ver.

t hereby placing t he

s ide holes in the biliary ste nt are not pos itioned near

The end of the Silastic stent that emanates from the superior surface of t he

li ver is brought

to the skin with 5-0 stainless steel wire, and connected to depend.ent bile bag

drainage. The egress site of the

brought out through a separate stab wound in the right upper quadra nt. The resected s urface of the liver and hepaticojejunostom y are drained with a Sil astic sump drain and either Penrose or closed suction drains brought out through

s eparate stab wounds in the mid abdomen. The Roux-en-Y loop is s utured to t he rent in the transverse mesocolon to prevent small bowel herniation (P). Postoperatively cholangiography is performed at five days and if no bile

leaks are present, the s tent is internali zed by placing

heparin lock on the end of the stent. Patients are taught to irrigate the stents

three times a day with 20 ml

Pos tope ratively patients are given adjuvant therapy wit h 5,000 rad of external beam rad iotherapy to t he area of the porta hepat is. When this is co mple t ed, the patient is readmitted to the ho s pital for approximately 48 hours so t hat iridium 192 seeds can be lowered down through th e biliary ste n t and pos itioned in the area of the anastomosis. An additiona l 2,000 rad of

radiotherapy are delivered loca lly. The Silastic trans hepatic biliary stents are left in permanently. Even

though an occas ional cure is possible, most patients will develop recurrent

tumor; th us hav ing t he s tent in place

and prolong urvival maximall y. Th e s tents, however, are changed every three or four months prophylactically becau se of biliary sludge accumu lation a nd obstruction of the side holes . T his is easily and quickly carri ed ou t as an outpa .em procedure under fluoro copy in the Catheter izat ion La bora tor y.

out through a stab wound in the r ight upper quadrant, s u tu red

biliary stent is drained wit h a Si lastic sump

a three-way s topcock or

of sal in e.

will prevent recurrent biliary obstruction

Q

SiIaslic biliaJy sterol p Middle hepatic v. Hepaticojejunostomy Roux·en-Y jejunal loop Silastic -~ a.-- !!
SiIaslic
biliaJy
sterol
p
Middle hepatic v.
Hepaticojejunostomy
Roux·en-Y
jejunal loop
Silastic
-~ a.-- !!
,--
biliary
stent
~ --'-'-'-----'--
Transverse mesocolon
tacked to jejunal loop
Duodenum

Proximal Cholangiocarcinoma:

Palliation by Transhepatic Stenting and Hepaticojejunostomy

Operative Indications

A ll patients w ith proximal cholangiocarcinomas ar e st aged preoperatively by percutaneous cholangiography an d a ngiography. If it appears that a patient is not potentiall y resectable fo r cure, palliation is achieved with Ring catheters, and the patient is not

explored. Such patients can receive palliative irradiation foll owing tissue confirmation of their disease. Of those patients explored who are thought to be curable, at t he t ime of

su rgery only half will be resectable. The others at the time of laparotom y will be

unresectable because of tumor extens ion into both lobes or in volvem en t of the common hepatic artery or main portal vein . In such instances we feel that it is appropriate to replace the Ring catheters

with Silastic trans hepatic The thick-wall, large-bore

palliation than t he Ring ca the ters alon e. The y are more comfortable, are tolerated better by patients, and less frequent ly are associated with

comp lications s uch

diameter, they also are less likely to occlude with biliary sludge. Placing these Silas tic s ten ts is not wort h a laparotomy in a patien t who clearly is incurable by preoperative staging. However, if a pati ent has been explored with the hope of a curative resection, and it is not pos sible, th is procedure is appropriate and indicated.

Operative Technique

T he patient is explored through a right subcostal incis ion. T he two Ring catheters are prepped into the field so they are accessible to the surgeon. When tumor extension is found in to bot h lobes of th e liver (A), it

is importan t to confirm t he diagnosi s by bi opsy . T hi s ma y be difficu lt on frozen

sect ion, because of the fibrotic scl eros ing na tu re of the tumor. Nevertheless the

s urgeon s ho u ld pers ist so th a t

biliary s ten ts and to perform a hepaticojejunostomy.

Sil astic

transhepatic biliary stents provide better

abscess. Because of their in t ernal

as hematobilia and liver

r ad iothera py can be deli ver ed postoper atively.

In

prepa ration for removi ng t he ga llbl adder , the cyst ic ar tery is identified ,

doubly clamped, di\'ided, and ligated . At the sa me time the common hepatic duct

i mobilized and looped with a vessel loop (B).

8

Cystic duct
Cystic duct
Gall btadder Biopsy of I. hepatic ducl '#'-,,&-_ _ _ hepatic duct vessel loop
Gall btadder
Biopsy of I. hepatic ducl
'#'-,,&-_
_
_
hepatic duct
vessel loop

Enci rcling common

Biopsy of I. hepatic ducl '#'-,,&-_ _ _ hepatic duct vessel loop Enci rcling common DMded

DMded cys:x: a

T he gallbladder is mobilized, the common hepatic duct is divided , and then the distal common du ct is divided, removing the gallbladder and

a

segme nt of extrahepatic

either ligated or oversewn

bi li ary tree (C). The distal common duct is with interrup ted 3- 0 silks.

One is now left with a short segment of common hepatic duct, cholangiocarcinoma in volv ing the common hepatic duct and bifurcat ion and

extending up into

hepatic ducts (D).

With the large-bore, thick-wall Silastic stents residing in t he biliary tree, obstr uction of the cystic duct by edema or by the stents t hemselves is common, and ac ute suppurat ive cholecystitis ca n occur. Si nce t he distal biliary tree is of norma l size, it cannot accommodate the two large Silastic stents, and it is necessary to construct a Roux-en-Y jejunal loop as a receptacle.

both lobes, and Ring catheters in both the

righ t and left

It is important that t he gallbladder be removed.

,

• Mobilized gallbladder I.
Mobilized
gallbladder
I.

Dividing common dld

D

Tum or extend ing into ~d~~ : !.--- -- bolh lobes ~~~\- Common hepatic duel
Tum or extend ing
into
~d~~ :
!.---
--
bolh lobes
~~~\- Common hepatic duel
-"-- -,---- -
~-i-.-=--=:
,,----
Portal v.
Hepat i c a .
-~
common
du ct
(
UJ

T he curved ends of the Ring catheters are cu t off. The catheters are then brought into the peritoneal cavity through the chest wall. A

guidewire is inserted into each Ring catheter to maintain the tract in case a catheter breaks or becomes dislodged during the following

manipulations.

A #12 Coude catheter wi t h its tip cut off is then placed over the guidewire

and Ring catheter and sutured in place (E). The Coude catheters are drawn up through the tumor, thereby dilating it and placing the Coude catheters into the right and left hepatic ducts. Often this is repeated with the next size Coude catheter, for instance #14, before placing

t he #16 French Silastic transhepatic

dilatation, one may have difficulty in placing the Silas tic trans hepatic biliary

stent. Using progressively larger Coude catheters, t he t umor is easily dilated and the Silastic stents placed (F).

biliary s tent. Wi t hou t progressive

E _ _ --C.;!-~ Tumor extending inIo both lobes 0/ liver Ring catheters \ .)
E
_
_
--C.;!-~
Tumor extending inIo
both lobes 0/ liver
Ring catheters
\ .)
Coude
ca theter
F
I
/.
J';r
Sit astlc
bitiary
I
stent
'_~ ng
/
,
C<CJheter
GUldewtre

O nce both Silastic tra nshepatic bi liary stents have been positioned, a

Roux·en ·Y loop 60 cm in length is constructed as previou sly

demon strated on pages 48-53. The anastomosis is performed

with a

si ngle layer of interrupted 4- 0 sy nthetic abso rb able mater iaL The

posterior row is placed prior to performing an enterotomy (G). The sutures pass

into the subm ucosal layer of the bowel and are through ·and·through on t he duct

side. Thus th e anastomosis

it acts as one. After the back row has been placed and the sutures secured, an enterotomy

is made with th e electrocautery (H). The posterior row of sutures is divided, and

both ste nts are placed into t he Roux·en·Y loop throug h

The knots of the posterior layer are on the inside, but since the suture material

is absorbable, th is is of

The anterior layer of the ana stom osi s is completed wit h a single interrupted layer of t hr ough ·and· th rough sut ures of 4- 0 synthetic absorbable material (I). All such sutures are placed and then secured .

is not actually mucosa·to·mucosa, but funct ionally

t he single enterotomy.

no consequence .

H

~ b6ary -- sIEnIS Poster ior row of hepaticojejunostomy ;:t , jejunal loop , ,
~
b6ary
-- sIEnIS
Poster ior row of
hepaticojejunostomy
;:t ,
jejunal loop
,
,
:
\
,
,
\
Enterotomy
of hepaticojejunostomy ;:t , jejunal loop , , : \ , , \ Enterotomy Anterior row

Anterior row of hepa ·cojejunos\DlnJ

B oth Silastic transhepatic biliary stents are brought out through stab wounds in the right and left upper quadran ts, s utured to the skin with 5- 0 stainless steel wire, and connected to gravity bile bag drainage. Both egress s ites on the superior s urface of the li ver are

drained with Silastic sump catheters, brought out through separate stab wo unds in the right and left upper quadrants. The anastomos is is drained with Penrose or closed suction drains brought out through a stab wound in the mid abdomen. The Roux·en ·Y loop is sutured to the under surface of the li ver with interrupted 3- 0 silks, and it is sutured to the rent in the transverse mesocolon with interrupted 4-0 silks (J). Postoperatively the stents are placed to bile bag drainage by gravity. At five days cholangiography is performed, and if there are no bile leaks, the stents are

internalized by placing three·way stopcocks or heparin locks on the ends. Patients are taught to irr igate the stents three times a day with 20 ml of sa lin e. The Silastic trans hepatic biliary stent s are left in permanently to maintain patency of the biliary tree. The stents are cha nged every three or four months as an outpatient procedure, however, to prevent side hole occlusion with biliary sludge. This is accomplished by passing a gu idewire t hrough the old ste nt into the jejunal loop and then removing the old stent, leaving the guidewire in place. A new stent is placed into the jejunal loop, over the guidewire, and the guidewire is removed.

Postoperative radi ation can

be delivered in a fashion s imilar to that after a

curative resection: 5,000 rad are deli vered to the hepatic duct bifurcation via external beam radiotherapy, and then the patient is readmitted for the delivery of interna l radiation via iridium 192 seeds lowered down through the lumens of the Silastic biliary s tent s. Such seeds are left in place for approximately 48 hours to deliver an additional 2,000 rad. This palliative procedure can prolong surv ival for as much as two years foll owing the ini t ial presentat ion.

J -'-_ -':=--_ Tu mor ex-~ both IOOes CJ' •"'" Roux-en- Y e ur.a _~¥
J
-'-_ -':=--_
Tu mor ex-~
both IOOes CJ'
•"'"
Roux-en- Y e ur.a
_~¥
Transve rse - - - -- -"'~if'
mesocolo n tacke d to
,
,
jejunal loop
• \
,
,
\
,
'
/
\
Transverse colon
P-"-----
-
End-la-side
jeJunojejunoslomy

Sase

boary

s;.ent

loop • \ , , \ , ' / \ Transverse colon P-"----- - End-la-side jeJunojejunoslomy
loop • \ , , \ , ' / \ Transverse colon P-"----- - End-la-side jeJunojejunoslomy
loop • \ , , \ , ' / \ Transverse colon P-"----- - End-la-side jeJunojejunoslomy

Resection of Hepatic Duct Bifurcation, Dilatation of Intrahepatic Biliary Tree, and Prolonged Stenting With Transhepatic Biliary Stents for Sclerosing Cholangitis

Operative Indications

S clerosing cholangitis is an idiopathi c disease that commonly affec ts

middle-aged males and is often associated with inflamma tory bowel

disease_ Patients with sclerosing chola ngiti s generally have diffuse

involvem ent of the intra - and extrahepatic biliary t ree, w ith multiple

benign inflamma tory strictures (A). Even though t he st ri cturing involves the intra- and extrahepatic biliary tree diffusely, the area of most severe

involvement is often the hepatic duct bi furcat ion. Most patients presen t with in ter mittent pain less

Patients with sclerosing cholangitis can have prolonged, variable, and episodic clinical courses. Howe ver, w hen persistent jaundice develops , it is a sign of a

poor prognosis. Such patien ts should undergo li ver biopsy. If biliary present, the patient is a candida te for liver t rarrsplan tation_

jau ndi ce and pruri tis_

cirrhosis is

Howeve r, if biliary cirrhosi s is not present, and th ere is a domi na nt

bifurcat ion stricture, the patient should be cons idered

hepat ic duct bifurcation, dila tation of the

stenting with transhepatic biliary stents, and bilateral hepaticojejunostomies_ Thi s proced ure is based on the premise that t he bifurcation st ricture and the

proximal obstruction pa rench ymal disease

s ign ificance of t he bifurcation stricture is often difficult to determine because of

the lack of proximal dilatation. In patients with scleros ing

bili ary t ree tends to be fibrotic, and it

st ricture_ Biliary tract surgeons have been slow to recognize the function a l

significa nce of t hese bifurcation

cho langiti s t he entire proximal to a

fo r resection of t he biliary t ree, long-term

intrahepat ic

that results pla ya major role in t he progress ive that eventually leads to hepatic fai lure_ The functional

often does no t di lat e

lesions_

T hus, patients wit h sclerosing cholangitis who have developed persisten t jaundice over a period of several months and are demonstrated

cholangiograph icall y to ha "e a dominant stri ct ure involving t he hepatic duct bifurcation, and who on li ver biops y do no t ha ve biliary cirrhosis, are th ought to

be e.xceUem

candidates for bi furca t ion r econs tructio n an d long-term stenting.

I'Teoperao\-e percutaneous cholangiography should be performed and Ring

catllet.tT.; bould be inserted into both the r igh t and left

£he bifurca - !kJicrure, and imo (he duodenum . These are placed

hepa ti c ducts, th rough

~.

in the

.

Il(){ W decompress (he h\-perbilirubinemia, but [0 aid the surgeon procedure.

Gall bladder

_

Ring catheters

+--- Bifurcation stricture

Duodenum

\

'1 ng catheters / Operative Technique P atients are explored through a generou diag nos
'1 ng catheters / Operative Technique P atients are explored through a generou diag nos

'1 ng catheters

/

Operative Technique

P atients are explored through a generou

diag nos is of sclerosing an in creased incide nce

cholangiti

right subcostal incision. At Gt'

ti me of laparotom y the abdomen i explored. The cholangiographic

is highly accurate. However, mere -

of cholangiocarcinoma developing in patien

wit h sclerosing cholangi t is ; th us t he abdomen should be explored for evidence ' t u mor. T he en tire ext r ahepatic bi liary t r ee is often scle r otic and fibrotic a demon s trated here (B). T he ga ll bladd er , however , grossly appears normal.

Th e bi furcation of

t he biliar y t ree can usua ll y be ide ntified h igh in the

porta hepati s by pa lpa ting fo r the poin t where t he t wo Ring catheters diverge

in to the ri gh t

and left hepatic ducts (B).

Gallbladder -

-r-,,:,-'

B

Hepatic flexure of co lon

Duodenum

Hepatic duct

bifurcation

A fter dividing the cystic artery, the gallbladder is mobilized to improve

access to the hepatic duc t bifurcation. Th e extrahepatic bi liary tree is

dissected, and the common

duct is encircl ed w ith a vessel loop

(C).

Th e distal common duct is divided, the two Ring catheters are

extracted, and the di s tal bil e duct is either ligated or closed with a series of interrupted 3-0 silk sutures. The proximal biliary segment is reflected in a cephalad direction, and the extrahepatic bili ary tree is dissected off the he pa t ic artery and portal vein (D).

The bifurcation of the hepatic du ct rests on the bifurcation of the portal

vein and the hepatic artery. Reflecting the proxima l biliary segment so the

biliary tree can be dissected both anteriorl y and posteriorly makes thi s a safe

dissection. The right and left hepatic ducts are dissected free and looped with vesse l loops. The right a nd left hepat ic ducts are then divided an d the specim en removed from the operati ve field (E).

c

Mobilized

gallbladder

l- --

Common duct

\

~\

(

Hepalic duct

"--,-

bifurcation

L hepatic duct

:4' -

-

He::-=2

~ ':-_ Pcr12I Y.

common

duct

T he next step involves dilatation of the fibrotic st rictu red intrahepatic biliary tree. Ring catheters have previou sly been placed through t he right and left hepa ti c ducts. The Ring catheters are retr ieved through

the chest and t he abdominal wall and

brough t in to t he peri to neal Ring cat hete r to avo id los ing

cavity . A gui dewir e is placed in

the t ract if a catheter breaks or becomes dis lodged in the next se ri es of

ma nipulations. A #12 Coude catheter is placed over the guide wire and on to the Ring

catheter after cutting off the cu rved distal tip of the Coude. The Coude is sutu red to the Ring catheter and then drawn up through the live r, th us dilating the intrahepatic biliary t ree (F). A #14 Coude cat heter is then placed over the guidew ire and sutured to the #12 Coude cat hete r. Further dilatation is accomp li shed by pull ing th e #12 Coude

cathe ter out through the top

t he lu men of the

of the li ve r , the reby pl aci ng the #14. Thi s ca n the n

be repeated with a Finall y, when

transhepatic biliary stent is sutured to the Coude and positioned by withdraw ing th e Coude cat heter (G). Thi s se ries of manipu lation s not only dilates the s trictu red intrahepat ic biliary tree , but also position s the Sil astic transhepa t ic biliary stents used in the reconst ru ction .

#16 Coude cat hete r. a #16 Coude catheter ha s been

placed, a #16 Sil astic

c '---- R. hepatic dud ;L --- - - L. hepatic duct Larger Goude catheter
c
'---- R. hepatic dud
;L --- -
-
L. hepatic duct
Larger
Goude catheter
Sma ll
Goude catheter
\
G
,
Guidewlre

11-'""-- -- --

catheter \ G , Guidewlre 11-'""-- -- -- SI aSLC biliary ------ s: " Large Goude

SI aSLC biliary ------

s:

"

Large Goude cathe '"

T he Si lastic transhepatic stents have both been positioned (H).

on t he s uper ior s urface of th e li ver around the egress

Matt ress s u t ures of #1 synthetic absor bable material may be placed

sites of t he two

s tent s to m inim ize t he li ke lihood of bi le drainage. T he process of

dila ting the intrah epa ti c bili a ry tree catheters in place. If Ring cat heter s have not been

dil ate the intr ahepatic biliary t ree afte r bifurcat ion resection with instruments

such as Bakes dilators. Th is can be extremely

cautious ly to avoid making fa lse passages . If a fa lse passage is made, it is

virt ua lly impossible to get beyond the fa lse passage to dil ate

wit hin the li ver. However,

eventually be perfor med. On ce th e int rahepatic bili ary tree is dil ated, the Bakes dilator can be pus hed out the di ap h ragmatic surface of the liver and a Si lastic stent s u t ured to it. The s tenti s positioned by withdrawing the Bakes catheter out the hilum of the liver (I). Securing t he Sil astic ste nt to t he Bakes dila tor is fac ili tated by having a hole drilled in the end of t he olive tip.

is grea tl y s implified by hav ing Ri ng

inse r ted preoper ative ly, it is necessary to

tedious. One has to proceed

bi li ary tree up

by proceeding very cautiously , dilatation can

H 1"'---- - L. hepatic duct , TSi lastiC biliary stents A. and I. hepatic
H
1"'---- -
L. hepatic duct
, TSi lastiC biliary stents
A. and I. hepatic ducts

Olive tip of Bakes dilator

- L. hepatic duct , TSi lastiC biliary stents A. and I. hepatic ducts Olive tip

Sa! es dilator

A RoUX-en -y loop 60 cm in length is constructed as previously described

on pages 48-53. It is brought into the right upper quadrant in a

ret rocolic position on top of the second and th ird portions of the

duodenum.

Bilatera l hepati cojejunostomies are t hen performed. T hese are constructed in one interrupted layer us ing 4- 0 synt hetic absorbable sut ure material. Th e

sutu res pass into the submucosal layer of the jejunum and t hrough and through the duct. The entire posterior row is placed for each hepaticojejunostomy before the sutures are secured . The intestinal sutures are placed in the posterior row

prior to

mucosa anas tomos is, alt hough functionally it acts as one. Each sut ure is grasped in a separate hemostat and lin ed up

longer clamp (J). Once all the sut ures have been

posterior row are on the inside, but since the suture material is absorbab le, this is of no long-term conseq uence. Bilateral enterotomies are performed with the electrocautery (K). The posterior row of sutures is divided, and the Silastic tra ns hepatic biliary stents are placed through the enterotomies in to the Roux-en-Y loop (L). The anterior rows of both hepaticojejunostomies are comple ted utilizing through-an d-through simple sutures of 4-0 synthetic absorbable material (M).

performing an enterotom y, so st ri ct ly speak ing, it

is not a mucosa-to-

in order on a

placed, they are secured . The knots of the

J I " f.
J
I
"
f.
Roux-en - Y jejunal loop
Roux-en - Y
jejunal loop

Silastic biliary sten ts

" f. Roux-en - Y jejunal loop Silastic biliary sten ts I . .~ 1 Enterotomies

I

f. Roux-en - Y jejunal loop Silastic biliary sten ts I . .~ 1 Enterotomies R.

.

.~

1

Enterotomies
Enterotomies

R. hepat ic duct

Posterior

rows of

anastomoses

MerU rows 01 ana::.stai-
MerU
rows 01
ana::.stai-

B oth s ilastic t ranshepatic biliary stents emanating from the

se parate stab wo unds in the

top of the right and

liver are broug ht out t hrou gh

left upper quadrants, s utu r ed

to s kin with 5-0 stainless steel wire,

and conn ected to gravity bile bag drainage. Both egress sites on the

superior surface of t he liver are drained with Silastic sump drains brought out

through separate stab wounds in the right a nd left upper quadran ts.

The Roux-en-Y loop is s u t ured to th e under surface of th e live r with

interrupted 3-0 silks, a nd

is s utu red to t he defect in the tran sverse mesocolon with in terrupted 4- 0 silk (N) . The hepaticoj ejunostom ies are drained with Penrose or closed suction

drains.

to prevent sm all bowel hern iation, the Roux·en-Y loop

drainage fo r five days .

Postoperatively the stents are left to gravity

At five days cholangiography is performed, and if no leaks are apparent, t he

stents are internali zed by capping them with three-way stopcocks or heparin

locks . The patients are ta ught to irrigate the stents three times a day with

20 ml of sa line.

It has been our practice to leave t he Silastic stents in perma nen tly. The stent s, however, are changed every three or fo ur mon ths as a n outpatien t procedure. Patients come in and under fluoroscopy a guidewire is placed

through the old stent into the Roux·en-Y loop. The old stent is removed, leaving

t he guidewire in place. A new stent is the n s lipped

and the guidewire removed. Patients with sclerosing cholangitis tend to form biliary sludge more rapidly than patients with other disorders. Therefore it is occasionally necessary to change the stents more frequent ly t han every three or four

months. Patients w ho have done well for several years, with no difficu lty, have

had their s tents removed, stage. However , for ma ny

inevitable restricturing. This operative procedure has been demonstrated to prolong survival and to res ult in a prolonged drop in serum bilirubin. If a patien t's disease subsequen t ly progresses, this procedure does not obviate liver t ranspla nta tion . Several of our

patients have su bseq uent ly und ergone s uccessful li ver tr a nsplantation.

in place over t he guidewire

assuming their disease is in a quiescen t arrested patients t he stents are left in permanent ly to prevent

--~ +---:-;!=';----_ Roux-e n - jejunal loop fF- - - -- - Hepa cOlel" ~
--~ +---:-;!=';----_ Roux-e n -
jejunal loop
fF-
-
-
-- -
Hepa cOlel"
~
I
Transverse m'es.x:c>lo<o
lacked 10 l e, una 1000
I

'f-,~~- - - ---- End-Io-side

Transverse m'es.x:c>lo<o lacked 10 l e, una 1000 I 'f-,~~- - - ---- End-Io-side jejunojejunostomy 101

jejunojejunostomy

Hepaticojejunostomy for Distal Stricturing Secondary to Sclerosing Cholangitis

for Distal Stricturing Secondary to Sclerosing Cholangitis Operative Indications T he majority of patients with

Operative Indications

T he majority of patients with scleros ing cholangiti have biliary s trictures in volvi ng both the in tra- and extrahepatic biliary mentioned in Operative Indications for the prior procedure, !:be severe stricturing is often at or near the hepatic duct b- -

Some patients wi th sclerosing cholangitis, however, have a variant in -

strictu ring is confined to the di stal biliary tree (A). These

conveniently managed with a distal biliary tree resection and a proximal hepaticojejunostomy _Operative indications for such patient would -u rltu tb development of persistent jaundice or recurrent cholangitis_

development of persistent jaundice or recurrent cholangitis_ patients can be If liver biop sy demonstrates biliary

patients can be

If liver biopsy demonstrates biliary cirrhosis, liver tran plantari

be cons idered . If cirrhosis is

hepaticojejunostomy should be considered.

Operative Technique

not present, however , a biliary recon

Operative Technique not present, however , a biliary recon :;. T he patient is explored through

:;.

T he patient is

explored through a righ t subcostal inci ion. Many

patients will have been operated upon previously; often they undergone a cholecystectomy wit h inse rt ion of aT- tube for- prolonged T-tube drainage.

At the time of exploration for hepaticojejunostomy , if

the gallbladder- -

exploration for hepaticojejunostomy , if the gallbladder- - in place, it is removed. The duodenum is

in place, it is removed. The duodenum is exte nsively kocherized (8)-

Gallbladder

B Ga ll bladder fossa

Duodenum

~---- CamJon h<lpaIic a.:Jd

DIseased disIaI

COIiitiO. doc:t

--

Kocherized duodelll.m

l ,:::~:-,.---:=------'---- Pa ncreas

M an y of these patients preopera ti vely at the

wi ll have had Ring catheters in serted time of percutaneou s cholangiography.

However, with the disease confined dista lly in the extrahepatic biliary tree, this is option;;l and often a Ring catheter will

not be inserted. The extrahepatic biliary tree is dissected free, and the distal common duct is mobilized and looped with a vessel loop (C). The dissection is carried proximally to the point wher e the hepatic duct appea rs grossly normal. The common hepatic duct is mobilized and a transverse anterior choledochotomy performed (D). At this point an opt ional step includes choledochoscopy with either a right· angled rigid scope (E) or a flexible fiberoptic choledochoscope. Since patients with sclerosing cholangitis are prone to develop cholangiocarcinomas, choledochoscopy at the time of this procedure can be important.

~

and duct _

a

_

\',

ormaJ common hepabc duct