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A Roux-en-Y loop of upper jejunum is brought into the right upper quadrant through an avascular area of the mesocolon and anterior to the second and third portions of the duodenum. The opening in the mesocolon is closed about the jejunum and its mesentery after making certain the end of the Roux-en-Y extends up to and slightly beyond the hepatic duct openings. The end of the jejunum is closed with staples or in layers of running or interrupted sutures. The posterior wall of the jejunum in the region of the anastomosis should be anchored to the capsule of the liver or adjacent tissue.

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It is helpful to insert interrupted sutures through the lateral angles of each open duct for positioning and sizing an accurate anastomosis on the jejunum (Figure 10). A posterior row of sutures is placed using the full thickness of each duct. None of these sutures is tied until all posterior sutures are in place for each duct. The middle suture in the posterior row may also be used to tie about the stent, so as to help prevent migration of this tube.

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The knot of the back suture line will be on the inside. The sutures are cut at the knot, except for the suture at each angle. A small incision parallel to the posterior suture line is made in the jejunum (Figure 11).

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The ends of the Silastic biliary stents are gently introduced into the lumen of the jejunum (Figure 12). Anterior, full-thickness suture lines are closed on both ducts (Figures 13 and 14). Last, the jejunum is anchored to the adjacent liver. Regional closed-system Silastic suction catheters are placed and the Silastic transhepatic stents are doubly sutured to the skin with 5-0 nylon (Figure 15). The abdomen is closed in a routine manner and the stents are connected to a sterile plastic bag to allow drainage by gravity.

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The closed system Silastic sump drains are removed after 5 or 6 days unless there is a significant bile output or a leak is shown on cholangiography. If no leaks are found from the superior surface of the liver or the anastomosis, three-way stopcocks are attached to the end of the catheters. The patients ...

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