Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)
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4 4 0 S E C T I O N V • G A L L B L A D D E R
A transverse duodenotomy is then performed adjacent to the choledochotomy using electrocautery (Figure 42-4, A).
3.ANASTOMOSIS
Absorbable 4-0 Vicryl sutures are used to perform a single-layer, side-to-side anastomosis. A stitch is first placed at the inferior apex of the choledochotomy, through the center of the back wall of the duodenotomy with the knots placed on the outside. This apex suture is tied (see Figure 42-4, A).
Next, lateral stay sutures are placed. They pass from the midpoint of the choledochotomy on each side to the respective end of the duodenotomy. These sutures are not tied and are placed in hemostat clamps (Figure 42-4, B). Holding these stay sutures out laterally nicely aligns the bile duct and duodenum for placement of the remaining sutures.
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B
FIGURE 42–4
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The anterior row is then completed in similar fashion. An apex stitch is placed from the midpoint of the duodenotomy to the superior apex of the choledochotomy (Figure 42-6, A). The remaining stitches are placed in the anterior bile duct (Figure 42-6, B). To allow for easier suture placement and careful approximation of the bile duct and duodenal mucosa, the anterior sutures are all placed before they are tied down.
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FIGURE 42–6
C H A P T E R 42 • Choledochoduodenostomy and Hepaticojejunostomy |
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HEPATICOJEJUNOSTOMY
1.INCISION
The operation is performed through a right subcostal incision or an upper midline incision
(Figure 42-7).
FIGURE 42–7
Proximal
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After all the sutures in the posterior row have been placed, the jejunum is telescoped down to the bile duct and all of the sutures are tied, including the corner sutures. The corner sutures are placed back in hemostats and the other sutures are cut.
After tying the posterior row of sutures, the surgeon makes a small enterotomy in the jejunum (Figure 42-16, A). If a biliary stent is used, the surgeon places the distal end into the jejunal limb at this point.
The anterior layer of the anastomosis is completed using interrupted 4-0 Vicryl sutures through both the jejunum and the bile duct (Figure 42-16, B).
After construction of the hepaticojejunostomy, the surgeon perfoms a standard two-layer end-to-side jejunojejunal anastomosis to restore bowel continuity. The posterior row of interrupted 3-0 silk is shown in Figure 42-17, A. The running inner layer of 3-0 Vicryl is shown in Figure 42-17, B. This is a running, locking suture in the posterior row and a Connell stitch in the anterior row. Figure 42-17, C shows the interrupted layer of 3-0 silk sutures used to complete the anterior row.
Figure 42-17, D shows the completed anastomosis. Interrupted 3-0 silk sutures are used to close the mesenteric defect at the jejunojejunal anastomosis (see Figure 42-17, D) and to tack the Roux limb to the transverse mesocolon, where it passes retrocolic to prevent internal herniation.
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B
FIGURE 42–16