Plate 103

Details of Procedure

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).

Closure

The tube is brought out through a separate stab wound to one side or the other of the incision and anchored securely in place with nonabsorbable suture material. The wound is closed in layers after suction drainage is instituted to the undersurface of the liver by a plastic tube with many perforations.

Postoperative Care

The tube going to the anastomosis is placed on low-grade constant suction to divert bile until the newly made junction is healed. The appropriate antibiotic therapy should be adjusted following culture and sensitivity studies of the bile. The tube may be irrigated with saline intermittently to wash out all debris or small calculi. In addition, the tube provides a means of taking postoperative transhepatic cholangiograms from time to time to evaluate the security of the anastomosis and the evidence of regression in the size of the formerly obstructed ducts. Ordinarily, the tube is left in place for a minimum of four months. A complete evaluation with liver function studies and several cultures of the bile should be made, as well as a cholangiogram, before it is advisable to remove the tube.

In rare instances the common duct may be divided accidentally and the injury discovered at once. This is likely to occur just below the junction of the hepatic and cystic ducts as a result of technical errors. The surgeon should always inspect the common and hepatic ducts at the completion of cholecystectomy to make certain that they are not angulated or otherwise injured. If there is any question, sufficient time should be spent to make certain that the extrahepatic biliary system has not been damaged. If the common duct has been divided completely, a direct end-to-end anastomosis may be performed in some situations; however, it is preferable to perform a choledochojejunostomy because of damage to the blood supply of the duct.

The peritoneum on the lateral wall of the duodenum should be divided, and the duodenum should be mobilized to relieve any possible tension on the suture line. Clamps are not applied to the severed ends of the ducts. Irregular or frayed edges are excised, but clear zones are not created as the common duct has a very tenuous blood supply. That is to say, the common duct should not be cleaned either proximally or distally. Both ends of the duct are held in position with guide sutures of fine 0000 or 00000 nonabsorbable monofilament (Figure 7). The reconstruction is completed with fine 0000 or 00000 absorbable monofilament. A posterior layer of interrupted sutures is placed without entering the lumen to approximate the posterior duct walls (Figure 8). Upon completion of the posterior layer all of the sutures are divided except one at either angle to serve for purposes of traction (Figure 9). The posterior layers of mucous membrane are closed with very fine interrupted absorbable sutures. Following this the common duct is exposed for a short distance, preferably downward, to permit the opening of the duct, as in choledochostomy, and the introduction of a T-tube catheter (Figure 10). One arm of the tube is passed up beyond the suture line to ensure an adequate lumen for the duct when the anterior layer of sutures is placed, and the other is directed downward. If the duct has been divided quite low, the opening may be made above the suture line with one arm of the tube directed downward. The mucous membrane of the common duct is closed over the T-tube with interrupted 0000 absorbable sutures with the knots on the outside (Figure 11). The second layer of sutures is rarely necessary but may be placed close to the original layer to reinforce the line of anastomosis (Figure 12).

All the sutures taken in the duct must be accurately placed with small needles and fine 0000 or 00000 absorbable sutures and must include only a very small bite of tissue to avoid stenosis. After the anastomosis has been completed, saline is injected into the catheter to make certain that there is no leakage about the suture line, and a cholangiogram is made. A final inspection verifies the absence of undue tension on the suture line. A closed-system suction catheter made of Silastic is inserted past the foramen of Winslow into Morison's pouch.

Closure

The Silastic drain and common-duct catheter are brought out through a stab wound lateral to the incision. The wound is closed in the routine manner. The catheter is anchored to the skin with a silk suture and adhesive tape. Sterile dressings are applied.

Postoperative Care

See Plate 99.