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112 Atlas of Gastrointestinal Surgery: Gall Bladder and Biliary Tract
The Roux-en-Y loop is tacked to the rent in the transverse mesocolon with interrupted 4-0 silks to prevent herniation
of the small bowel (11). The Silastic transhepatic biliary stents are brought out through stab wounds in the right and left
upper quadrants, sutured to the skin with 5-0 stainless steel wire, and connected to dependent bile-bag drainage. The
egress sites of both stents on the superior surface of the liver are drained with closed-suction Silastic drains brought out
through separate stab wounds in the right and left upper quadrants. A third closed-suction Silastic drain is used to drain
the hepaticojejunostomy, and is brought out through a stab wound in the mid abdomen.
Intrahepatic
ductal cysts
Transverse mesocolon
tackeed to jejunal loop
Transverse colon
Hepaticojejunostomy
11
Roux-en-Y jejunal loop
End-to-side
jejunojejunostomy
Transhepatic Stenting for Caroli’s Disease 113
Cholangiography is obtained through the stents on the fifth postoperative day. If there are no leaks, the stents are internalized by placing three-way stopcocks or heparin locks on the ends. The patients are taught to irrigate the catheters twice a day
with 20 mL of saline. The stents are left in permanently in patients with Caroli’s disease in an attempt to achieve adequate
drainage, avoid stasis, and prevent episodes of cholangitis and jaundice. Whether or not transhepatic stenting decreases the
likelihood of the development of cholangiocarcinoma is unknown. The stents are changed as an outpatient procedure every 3
or 4 months. During long-term follow-up, the transhepatic stents provide access for repeat choledochoscopy to look for evidence of the development of cholangiocarcinoma. Guidewires can be placed through the stents into the Roux-en-Y loop and
the biliary stents removed (12).
Partially removed
Silastic biliary stent
12
Guidewires
Roux-en-Y
jejunal loop
114 Atlas of Gastrointestinal Surgery: Gall Bladder and Biliary Tract
Using the guidewire, a flexible choledochoscope can be placed
through the skin opening and guided down into the intrahepatic biliary tree (13). Suspicious areas can be biopsied.
Hepaticojejunostomy
Cystic
dilation
Flexible
choledochoscope
13
Endoscopic view of
hepaticojejunostomy
Wedge Resection of Liver and Regional Lymph
Node Dissection, Resection of the Extrahepatic
Biliary Tree with Hepaticojejunostomy, for
Carcinoma of the Gall bladder
Operative Indications:
Carcinoma of the gall bladder is in many instances an incurable disease, and the surgeon’s role
is merely a palliative one. Often, patients with carcinoma of the gall bladder present with obstructive jaundice, with tumor extending beyond the gall bladder into the liver, and with involvement of the extrahepatic biliary tree,
Common hepatic duct
with extension to involve the portal vein and hepatic artery. Such
patients are best palliated by the percutaneous insertion of a
transhepatic biliary stent, or by endoscopically inserting an
endoprosthesis to decompress the obstruction. An occasional patient presents with biliary symptoms and gallstones and undergoes an elective laparoscopic cholecystectomy. At the time of pathologic examination of the
gall bladder, an incidental adenocarcinoma will be
found. These patients with incidental gall bladder cancer are the ones with the greatest potential for long-term
survival. Occasional patients present between these two
extremes, where the neoplasm still appears to be confined
primarily to the gall bladder, surrounding liver parenchyma, and
regional lymph nodes (1). Although the vast majority of these patients
Large
gallstone
1
Lymph
nodes
Celiac
axis
Gall bladder
cancer
Duodenum
will not be cured, some clearly will benefit from a regional procedure.
116 Atlas of Gastrointestinal Surgery: Gall Bladder and Biliary Tract
Operative Technique:
The patient is explored through a right subcostal incision. At the time of laparotomy, a
thorough exploration of the abdomen is carried out to be certain there is no evidence of
disseminated disease beyond the immediate region of the gall bladder and the liver, or
to extrahepatic serosal surfaces. At the time of exploration, a patient who had a preoperative imaging CT scan or MRI suggesting gall bladder cancer will generally have a hard,
thickened and whitish appearing gall bladder (2). If there is no other evidence of tumor,
a cholecystectomy can be performed and the diagnosis confirmed by frozen section. If it
is obvious from the beginning that a carcinoma of the gall bladder is present and can be
confirmed with a biopsy, then the wedge resection of the liver can be carried out con-
Gall bladder
2
Gastrohepatic
ligament
of colon
DuodenumHepatic flexure
Wedge Resection of Liver and Regional Lymph Node Dissection, Resection of the Biliary Tree with Hepaticojejunostomy 117
current to performing the cholecystectomy. If the
patient has already had a laparoscopic cholecystectomy and the diagnosis confirmed, one proceeds
Gall bladder
with a wedge resection of the gall bladder bed
fossa
in the liver.
The hepatic flexure of the colon and
omentum are dissected free and retracted
inferiorly (3).
Duodenum
Hepatic flexure
of colon
Common
hepatic duct
Scoring liver
for wedge
resection
Common
hepatic duct
3
Since this patient has already undergone a
laparoscopic cholecystectomy, using the
electrocautery, the margins of the wedge
resection can be outlined on the liver,
surrounding the gall bladder bed (4).
The wedge resection can be performed
utilizing a variety of techniques. Many
surgeons prefer to use the Cavitron or
TissueLink for such nonanatomical liver
resections. In this example, we demonstrate
a technique of utilizing a series of overlap-
ping No. 1 chromic catgut mattress sutures to
compress surrounding hepatic parenchyma. The
chromic catgut sutures compress the liver
4
parenchyma, thus achieving hemostasis without
compressing the liver to the point where necrosis
118 Atlas of Gastrointestinal Surgery: Gall Bladder and Biliary Tract
occurs. The actual resection is then carried out with the electrocautery,
using the ball tip (5). Generally, a 2 cm margin can easily be obtained
using this technique. which results in a virtually bloodless resection.
Small bleeding points or small bile ducts are further controlled
with suture ligatures. Hemostasis can be achieved using the
electrocautery and the argon beam coagulator.
Overlapping mattress sutures
wedge resection
of gall bladder fossa
Wedge Resection of Liver and Regional Lymph Node Dissection, Resection of the Biliary Tree with Hepaticojejunostomy 119
Following the local wedge resection of the liver, a regional lymph node dissection is carried out removing all lymph nodes
and surrounding areolar tissue from the bifurcation of the common hepatic duct down to the distal common duct and medially along the hepatic artery over to the celiac axis (6). Many nodes are actually posterior to the biliary tree. In the past,
we have tried to perform this lymphadenectomy without removing the extrahepatic biliary tree. This is very difficult, and we
now routinely divide the common hepatic duct just distal to the bifurcation, and include the entire extrahepatic biliary tree
with the porta hepatis lymphadenectomy. This also gives a bigger margin on the gall bladder than just the cystic duct if only
a cholecystectomy is performed. Following laparoscopic cholecystectomy, we have had instances when a normal-looking extrahepatic biliary tree has been removed in the course of the porta hepatis lymphadenectomy, and a histologically positive cystic duct margin has been found.
Site of
wedge
resection
Duodenum
120 Atlas of Gastrointestinal Surgery: Gall Bladder and Biliary Tract
Following the porta hepatis lymphadenectomy, a Roux-en-Y jejunal loop 60 cm in length is constructed in the fashion
previously demonstrated (see “Insert Section Here”). It is brought up into the right upper quadrant through a rent in the
transverse mesocolon on top of the second and third portions of the duodenum. A hepaticojejunostomy is performed with
a single layer of interrupted 4-0 absorbable synthetic material (7) as previously described (see “Insert Section Here”).
Stenting of the anastomosis is not necessary. We have generally followed the principle that, if tumor is present in the segment of liver removed with the wedge resection and/or positive lymph nodes or a positive cystic duct margin is present,
post-operative adjuvant therapy is carried out using both radiotherapy and chemotherapy. If these three areas are negative,
adjuvant therapy is not used.
7
