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 and the undersur-face of the liver is retracted upward, the upper portion of the dilated duct may be verified by aspiration of bile through a fine hypodermic needle (Figure 3), and a cholangiogram may be performed. The needle may be left in place, and an incision is made alongside the needle until a free flow of bile is obtained. A blunt-nosed, curved clamp is inserted upward into the dilated duct and the opening gradually enlarged by dilatation, which may include an additional incision to enlarge the opening. No effort is made to free up the entire circumference of the ductal system, since the mucosal graft will eventually be intussuscepted well up into the duct without a direct end-to-end anastomosis (Figure 6).
Following the opening of the dilated common hepatic duct, a long, curved clamp is inserted, usually toward the left side, and extended up through the liver substance. A rubber or Silastic tube (14 or 16 French) is pulled down through the liver and partially out through the duct opening (Figure 4). Additional holes that will be above and below the anastomosis are made in this tube. Following this, a 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 arm is closed with two layers of interrupted silk. On the antimesenteric border of the jejunum a 5-cm segment of the seromuscular coat is excised approximately 5 cm from the closed end (Figure 4). Care should be taken to avoid making any additional openings in the mucosa except in the very apex of the protruding mucosal pocket. The tube that was pulled down through the liver is now directed through the small opening made in the apex of the mucosal pocket and directed down into the arm of jejunum for 10 cm or more. A purse-string suture of absorbable suture is placed in the mucosa about the tube and tied. After the tube has been passed the desired distance down the Roux-en-Y limb, a No. 2 absorbable suture is passed completely through the jejunal walls and around the tube to fix it in position when tied just distal to the mucosal outpocketing. A centimeter or two distally a similar absorbable suture is taken to ensure further fixation (Figure 6, A and B). These are the only sutures utilized to fix the tube to the wall of the jejunum. These sutures ensure fixation of the jejunal mucosa to the tube as it is withdrawn. Several holes are cut around the tube just above the mucosal graft to ensure drainage of the right as well as the left hepatic duct. Traction then is placed on the end of the tube coming out of the dome of the liver in order to pull the mucosal graft carefully and firmly up into place inside the common hepatic duct. This provides an intussusception of the jejunal mucosa up into the dilated common hepatic duct and ensures direct mucosa-to-mucosa approximation (Figure 6). In very high strictures it may be necessary to use a tube into the left as well as the right hepatic radical. Special tubes have been devised for very high strictures that separate the right from the left hepatic ducts. The Roux-en-Y loop is securely anchored in place beneath the liver by several absorbable sutures placed through the seromuscular coat and the scar tissue around the opening into the duct system (Figure 5).