Roux-en-Y hepaticojejunostomy is indicated for biliary reconstruction for a benign bile duct stricture, for bile duct injury during cholecystectomy, when a choledochoduodenostomy (see Chapter 77) is not possible, or as part of standard gastrointestinal reconstruction for oncologic operations (e.g., pancreatoduodenectomy or extended hepatectomy for bile duct cancer).
Patients should be nutritionally optimized without evidence of cholangitis or sepsis. Attention to history of prior abdominal operations, the presence of biliary anatomic variations, and the location of biliary stents is critical. Preoperative antibiotics are indicated prior to incision.
The skin is prepped and draped. Then a time-out is performed.
Surgery can be performed through a midline, right subcostal, or bilateral subcostal incision. After entering the abdomen and dividing the round ligament, a self-retaining retractor is inserted to maximize exposure.
Attention is first given to the right upper quadrant. Any adhesions between the duodenum and hilus of the liver are divided carefully by sharp and blunt dissection (FIGURE 1). If not previously performed, cholecystectomy is conducted first (see Chapter 74). The cystic duct stump then can be used to identify the common bile duct. If cholecystectomy has been performed previously, careful dissection should be undertaken to identify the bile duct. 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. The second portion of the duodenum can be mobilized medially (Kocher maneuver; FIGURE 2) if additional exposure is needed. In the presence of previous surgery or a bile leak, 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 facilitates dissection. The upper portion of the dilated duct may be verified by aspiration of bile via a 25-gauge needle (FIGURE 3). A cholangiogram also may be performed. Once the common bile duct is identified, it should be carefully encircled just cephalad to the origin of the cystic duct. The surgeon should be careful to not inadvertently injure the right hepatic artery, which often courses directly posterior to the common hepatic duct (FIGURE 4). An effort is made to free up the entire circumference of the proximal hepatic duct in order to create an end-to-side anastomosis with the jejunum.
In general, a Roux-en-Y configuration consists of a Roux limb that is brought into the upper abdomen for anastomosis to the organ of ...