Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)

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The completed operation is shown in Figure 42-18.

4.CLOSING (CHOLEDOCHODUODENOSTOMY AND HEPATICOJEJUNOSTOMY)

A closed suction drain is used to drain the choledochoduodenostomy or the hepaticojejunostomy in the event of bile leakage.

The fascia is closed in running or interrupted fashion per the preference of the surgeon. Absorbable or permanent sutures can be used.

The skin is closed with skin staples or absorbable subcuticular sutures.

FIGURE 42–18

STEP 4: POSTOPERATIVE CARE (CHOLEDOCHODUODENOSTOMY

AND HEPATICOJEJUNOSTOMY)

Postoperative complications include bile leak, stricture at the hepaticojejunostomy, cholangitis, and hematoma/bleeding.

If a percutaneous biliary stent was placed before surgery, it should initially be placed to external drainage. Before removal of the drain, the biliary stent should be capped off, internalizing the drainage.

The output from the operatively placed drain should be monitored. If no bilious drainage is observed after 4 to 5 days (and after internalization of biliary drainage if stent is in place), the drain can be removed.

If bilious drainage is noted, it can initially be managed conservatively with continued observation. Large leaks may require the placement of a percutaneous biliary drain to divert the bile flow externally while the anastomosis heals, if one was not present preoperatively.

Biliary stents, if present before surgery or placed after, should be left in place at least 6 weeks before removal.

An NG tube is kept in place the evening of surgery and removed on postoperative day 1.

Clear liquids are started in 48 to 72 hours, and the diet is advanced as tolerated.

The duration of stay is usually 5 to 8 days.

STEP 5: PEARLS AND PITFALLS

In the past, percutaneous biliary stents were commonly placed before hepaticojejunostomy. Many studies show that infectious complications are increased if a biliary stent is placed preoperatively, presumably caused by bactobilia. However, if cholangitis is present preoperatively, a percutaneous or endoscopic stent is needed to relieve the obstruction and prevent sepsis. Cholangitis is uncommon in malignant obstruction. The data were from patients undergoing pancreaticoduodenectomy and have been extrapolated to hepaticojejunostomy alone.

Tumors arising at the confluence of the right and left hepatic ducts require resection of the extrahepatic biliary tree, including the confluence, and require bilateral hepaticojejunostomies for reconstruction. In this case, bilateral preoperative stents may make the small anastomoses easier and prevent postoperative stricture formation.

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Preoperative biliary stents may also be helpful in the event of common bile duct injury to control leakage and make the anastomosis in a normal caliber bile duct easier.

In the nondilated bile duct, it is best to perform the enterotomy in the jejunal limb before performing the posterior row of the hepaticojejunostomy to prevent occlusion of the lumen by excess tissue. This is not a problem in dilated bile ducts.

With distal common bile duct stricture, malignancy should be considered and ruled out before biliary bypass.

SELECTED REFERENCES

1. Cameron JL: Atlas of Surgery, vol 1. Philadelphia, BC Decker, 1990, pp 28-57.

2. Sohn TA, Yeo CJ, Cameron JL, et al: Do preoperative biliary stents increase postoperative complications? J Gastrointest Surg 2000;4:258-267.

3. Jagannath P, Dhir V, Shrikhande S, et al: Effect of preoperative biliary stenting on immediate outcome after pancreaticoduodenectomy. Br J Surg 2005;92:256-361.

4. Povoski SP, Karpeh MS, Conlon KC, et al: Association of preoperative biliary drainage with postoperative outcome following pancreaticoduodenectomy. Ann Surg 1999;230:131-142.

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Figure 43-2 represents pancreas divisum, the most common congenital anomaly of the pancreatic ductal system. Pancreas divisum occurs in approximately 6% to 7% of healthy patients at autopsy. It occurs in up to 10% to 20% of patients with recurrent acute pancreatitis. Pancreas divisum results from a failure of fusion of the dorsal pancreatic duct and the duct draining the uncinate process and head of pancreas. The result is that the major portion of the drainage of the exocrine pancreas is through the minor papilla, with only the duct to the uncinate process draining to the ampulla of Vater. The role of this anomaly in causing pancreatitis is unclear, but it is thought to be the cause in a small number of patients with recurrent acute pancreatitis, pancreas divisum, and a stenotic minor papilla.

STEP 2: PREOPERATIVE CONSIDERATIONS

The use of transduodenal sphincteroplasty is controversial in many settings. For many indications it has been replaced by endoscopic sphincterotomy via endoscopic retrograde cholangiopancreatography (ERCP). The decision to perform this operation depends on the surgeon’s expertise, the clinical situation, and the expertise of local gastroenterologists.

Transduodenal sphincteroplasty has been used in a variety of settings. The indications for transduodenal CBD sphincteroplasty include:

Calculous disease of the biliary tract not amenable to stone removal via ERCP.

Sphincteroplasty should be performed if the surgeon believes there are retained stones after CBD exploration.

Sphincterotomy and sphincteroplasty can be used to retrieve stones impacted in the distal CBD that cannot be removed with choledochotomy and CBD exploration.

Sphincteroplasty can be used to explore the CBD with a small-caliber duct in which choledochotomy and T-tube placement may be difficult.

Treatment of recurrent and acute pancreatitis with ampullary stenosis identified and no other cause of pancreatitis identified; considered a rare indication.

The use of sphincteroplasty and pancreatic duct septotomy for postcholecystectomy syndrome remains controversial.

CBD sphincteroplasty and pancreatic duct septotomy are often performed with minor papilla sphincteroplasty (see later) to ensure adequate drainage in patients with symptomatic pancreas divisum.

The indications for minor papilla sphincteroplasty include:

Recurrent acute pancreatitis (abdominal pain and hyperamylasemia)

Pancreas divisum with no other obvious cause of acute pancreatitis identified

STEP 3: OPERATIVE STEPS

1. INCISION

The patient is placed supine on the operating table, with both arms extended out to the side.

A fluoroscopy table or table with radiographic capability is needed for possible intraoperative cholangiography.

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2. DISSECTION

If the gallbladder is in place, a cholecystectomy is performed by dissecting the gallbladder out of the gallbladder fossa, from the fundus down to the cystic structures (see Figure 43-3). The cystic artery is identified and ligated.

The cystic duct is then opened and a biliary balloon catheter is placed into the CBD from the cystic duct. Cholangiography, if indicated, is easily performed at this point. The catheter should exit into the duodenum at the ampulla of Vater.

At this point the duodenum should be mobilized out of the retroperitoneum using the Kocher maneuver. Then the balloon should be inflated and pulled back flush to the ampulla of Vater and easily palpated (see Figure 43-3).

After palpating the balloon on the biliary catheter, the balloon is advanced into the duodenum. Two 3-0 silk stay sutures are placed to the right and left of where the duodenotomy will be performed. A longitudinal duodenotomy is made at the site of initial palpation right over the ampulla of Vater (Figure 43-4). This can be done with electrocautery.

The surgeon can then place his or her finger in the duodenotomy and palpate the balloon and ampulla of Vater. The duodenotomy is then extended distally for adequate exposure of the ampulla (Figure 43-5).

Absorbable 5-0 sutures are then placed medial and lateral to the exiting biliary catheter at the ampulla of Vater (see Figure 43-5).

Using the biliary catheter for guidance, the surgeon performs a sphincterotomy of the ampulla of Vater using electrocautery (see Figure 43-5). This should be performed slowly, 3 to 4 mm at a time for a total length of 1 to 2 cm. The length of the sphincterotomy will vary depending on the indication.

After the sphincterotomy is performed, the CBD mucosa is approximated to the duodenal mucosa using interrupted 5-0 absorbable sutures. The apex suture is shown in Figure 43-6, with several other sutures already in place.

Once the CBD is opened, the pancreatic duct orifice can be identified, and a lacrimal duct probe can be placed into the duct (see Figure 43-6).

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To ensure adequate drainage of the pancreatic duct, a pancreatic duct septotomy can be performed over the probe (Figure 43-7).

In the case of pancreas divisum, the duodenotomy may need to be extended proximally on the duodenum to identify the minor papilla. In cases where this is difficult to identify, secretin can be given to stimulate pancreatic secretion and aid in identification.

The minor papilla is small and can be difficult to cannulate. A small lacrimal duct probe should be used and inserted atraumatically to prevent hematoma at the minor papilla

(Figure 43-8).

After cannulation, a papillotomy can be performed over the probe using electrocautery similar to performing the sphincterotomy at the major papilla.

The pancreatic ductal mucosa is approximated to the duodenal mucosa using 5-0 absorbable suture, similar to the approximation of the CBD to the mucosa after ampulla of Vater sphincteroplasty.

After the sphincteroplasty is completed, the biliary catheter can be retracted and a cholangiogram performed if necessary.

The biliary catheter is then removed and the cholecystectomy is completed by ligating the cystic duct distal to the ductotomy made for the biliary balloon catheter, dividing the cystic duct, and removing the gallbladder from the field.

The duodenotomy is then closed longitudinally in two layers. Care must be taken not to narrow the duodenal lumen. Stay sutures of 3-0 silk are placed at the most proximal and distal points of the duodenotomy. The first layer is performed with absorbable 3-0 suture in Connell fashion (Figure 43-9).

The outer layer is closed in interrupted fashion using 3-0 silk suture (Figure 43-10).

A closed-suction drain is placed to drain the duodenotomy.