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In this chapter two techniques of Roux-en-Y choledochojejunostomy are described. The first is a direct mucosa-to-mucosa anastomosis and is the preferred technique. The alternate procedure of a mucosal graft was described by Sir Rodney Smith in situations where there is a very high structure or injury precluding direct visualization of the proximal biliary tree.
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The surgeon is occasionally faced with the difficult problem of finding the strictured area or blind end of the hepatic duct. The adhesions between the duodenum and hilus of the liver are divided carefully by sharp and blunt dissection (figure 1). Great care must be exercised to avoid unnecessary bleeding and possible injury to the underlying structures. Usually, it is easier to start the dissection quite far laterally and to free up the superior surface of the right lobe of the liver from the adherent duodenum, hepatic flexure of the colon, and omentum. Sharp dissection is used along the liver margins to avoid tearing the liver capsule, which results in a troublesome ooze. After the edge of the adhesion has been incised, blunt dissection will be more effective and safer in freeing up the undersurface of the liver. The exposure should be directed toward identifying and exposing the foramen of Winslow. The stomach may or may not have to be dissected away from the liver. Usually, the duodenum is drawn up into the old gallbladder bed and fixed by dense adhesions. The second portion of the duodenum is mobilized medially (Kocher maneuver), following division of the peritoneum along its lateral margin (figure 2). As the duodenum is reflected downward the undersurface of the liver is retracted upward. The scar tissue around the porta hepatis may obscure the biliary ductal system. It is best to approach the duct from the lateral side. Identifying the cystic duct stump is helpful in delineating the location of the biliary tree and will facilitate dissection. The upper portion of the dilated duct may be verified by aspiration of bile through a 25-gauge needle (figure 3). A cholangiogram may be performed. Sharp dissection should be used to identify the duct. An effort is made to free up the entire circumference of the ductal system in order to create an end to side anastomosis with the jejunum. A retrocolic Roux-en-Y arm of jejunum is prepared in the usual way using a linear staple to divide the small intestine. If the intestine is divided between clamps then the end of the mobilized jejunal limb is closed with two layers of interrupted silk. On the antimesenteric border of the jejunum about 5 to 10 cm distal to the divided end of the intestine, an incision slightly smaller than the duct opening is made with electrocautery. This should be easily approximated to the hepatic duct with no tension.
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DIRECT MUCOSA TO MUCOSA CHOLEDOCHOJEJUNOSTOMY
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