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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_738_Библиотеки_им_академика_М_И_Перельмана.pdf
Resection of a Benign Bile Duct Stricture
with Reconstruction Utilizing a
Hepaticojejunostomy
Operative Indications:
Benign bile duct strictures can follow a variety of clinical situations. Scarring and fibrosis of the head of the pancreas from
chronic pancreatitis can result in a distal biliary stricture. Mirizzi’s syndrome, with impaction of a cystic duct stone obstructing the common hepatic duct, can also result in a benign biliary stricture. The majority of benign strictures, however, follow operative trauma, usually occurring during a laparoscopic cholecystectomy. Occasionally during a gastrectomy, operative trauma can also result in a biliary stricture. Prior to the introduction of laparoscopic cholecystectomy in 1989, the
incidence of injury to the biliary tree during a cholecystectomy had fallen to approximately 1 in 1,000. Immediately following the introduction of laparoscopic cholecystectomy, the incidence increased to 1 in 100. Today, it has stabilized in
the range of 2 to 5 in 1,000 cholecystectomies.
The total number of benign biliary strictures secondary to cholecystectomy is actually greater now than it was a decade
or two ago, because of the introduction of laparoscopic cholecystectomy, and the higher incidence of injury. In addition,
the injuries tend to be higher up in the hilum, presumably because of the easier access to this area laparoscopically, compared to an open procedure. If the biliary stricture involves the mid- or distal portion of the extrahepatic biliary tree, the
repair is straightforward. The proximal biliary segment is dissected free, and a mucosal-to-mucosal anastomosis is performed
between the common hepatic duct and a Roux-en-Y jejunal loop. Long-term stenting is not necessary. A T-tube may be
used at the time of surgery to decompress the anastomosis, or if preoperatively inserted, a percutaneous transhepatic biliary catheter can be used. The T-tube or percutaneous biliary catheter can be removed 6 weeks after the repair. Today,
however, most biliary tract surgeons would use no stent.
Many, if not most, extrahepatic injuries that occur during laparoscopic cholecystectomy, however, involve the common hepatic duct proximally, near or even involving the bifurcation. These high strictures are more difficult to manage. In recent years, the
majority of patients referred to our institution with post-cholecystectomy strictures have had multiple ligaclips in the porta hepatis,
Resection of a Benign Bile Duct Stricture with Reconstruction Utilizing a Hepaticojejunostomy 43
and these often are found to be responsible for
the stricture (1). It is our practice to perform preoperative percutaneous transhepatic cholangiography on all
patients with a suspected stricture with the insertion of a per-
Cystic duct
stump
cutaneous biliary catheter. If the injury is acute, and there are bilomas or subhepatic abscesses, these are drained percutaneously. At the
time of percutaneous transhepatic cholangiography, the anatomy can be
clearly delineated and external biliary drainage established. If biliary continuity has not been totally disrupted, passing the percutaneous biliary
catheter through the area of injury into the duodenum will be important.
In these patients, internal biliary drainage can be established. Once the
bilomas and abscesses have been successfully drained and biliary drainage
established (either externally or internally), the actual repair is often delayed
for 6 weeks to 3 months, to allow the right upper quadrant inflammation to
1
Clip
Catheter in
duodenum
subside. If the injury is more chronic, however, and there is no evidence of biloma or intra-abdominal abscess formation, the repair can be carried out electively at
any time. If there has been no intra-abdominal leakage, at the time of laparotomy for biliary stricture repair the amount of inflammation and adhesions can be minimal, compared to the
era when most injuries were produced during open cholecystectomy.
Operative Technique:
Most patients today with benign biliary strictures will have undergone a cholecystectomy
laparoscopically. However, some of these patients will have been converted to an open
procedure. The patient is prepped and draped so that the percutaneous transhepatic biliary catheter is accessible in the prepped area during the procedure. The abdomen is
entered through a right subcostal incision. Upon entering the abdomen, adhesions are
encountered. These, however, are less severe following a laparoscopic cholecystectomy,
compared to an open cholecystectomy. The adhesions are dissected both sharply and
bluntly. By palpating in the porta hepatis for the previously placed percutaneous transhepatic biliary catheter, identification of the biliary tree is greatly facilitated. In the past, par-
ticularly if the patient had been operated upon several times, and no catheter was present
within the biliary tree, dissection to identify the proximal biliary segment took hours. However, with a catheter in place,
the dissection proceeds rapidly, and within a relatively short time, the proximal biliary segment can be identified.
44 Atlas of Gastrointestinal Surgery: Gall Bladder and Biliary Tract
Once the extrahepatic biliary tree has been identified, it is mobilized and encircled with a vessel
loop (2). Dissection then proceeds proximally towards the bifurcation. The proximal biliary segment
is frequently surrounded by a dense inflammatory reaction with fibrosis. Ligaclips often add to the
difficulty of the dissection.
Gall bladder
fossa
Strictured
common duct
(containing
catheter)
2
Resection of a Benign Bile Duct Stricture with Reconstruction Utilizing a Hepaticojejunostomy 45
Early in the dissection, one may choose to divide the biliary tree
(if it is still intact), extract the biliary catheter (3), and reflect the
proximal biliary segment in a cephalad direction thus more easily
exposing the portal vein and hepatic artery and its branches (4). As
the dissection proceeds proximally, one will come to the common
hepatic duct, or bifurcation, that appears reasonably normal. The distal portion of the biliary tree is dissected free down to the point
where the common duct passes posterior to the duodenum. At this
point the duct is divided (4) and the strictured extrahepatic biliary
tree removed from the operative field. If the biliary tree is not intact,
obviously only the diseased proximal biliary tree will be identified and
excised. Often the distal biliary tree is not identified.
Mobilized
distal
biliry tree
Normal hepatic
duct
bifuration
3
If the distal biliary tree is in continuity, once the strictured segment
is excised, the distal biliary tree should be closed with a series of 30 silk sutures (5). Occasionally, pancreatic juice will reflux into and
out of the distal biliary tree (if this segment is not closed) and result
in a subhepatic collection of pancreatic juice postoperatively. Generally, when one dissects the proximal biliary segment up
to the point where normal mucosa is identified, one is right at the bifurcation, which can easily be identified through the
open proximal biliary segment (4).
Common
duct closure
Division of
common
hepatic
duct
4
5
46 Atlas of Gastrointestinal Surgery: Gall Bladder and Biliary Tract
The percutaneous transhepatic biliary catheter, which has previously been
prepped and draped into the operative field, is then pulled through the chest
wall into the peritoneal cavity to expose its entry site on the diaphragmatic surface of the liver (6).
Percutaneous transhepatic
biliary catheter
6
Resection of a Benign Bile Duct Stricture with Reconstruction Utilizing a Hepaticojejunostomy 47
At this point, it is important to replace
the rigid percutaneous biliary catheter
with a soft Silastic biliary stent. To
avoid losing the tract if a catheter
should break or become dislodged during transfer, a
7
guidewire is placed through
the rigid biliary catheter
(7). A 14 or 16 French
Guidewire
Percutaneous
catheter
transhepatic Silastic biliary
stent is then threaded over
the guidewire, and over
the transhepatic biliary
catheter that had been
placed preoperatively. The
Silastic stent is sutured to the
transhepatic biliary catheter with two
mattress sutures of 2-0 silk (7). The biliary catheter is then pulled out through the superior surface of the liver, thereby positioning the Silastic tran-
Coudé cateter
shepatic stent in the right hepatic duct (8).
Side holes in
Silastic biliary
stent
8
48 Atlas of Gastrointestinal Surgery: Gall Bladder and Biliary Tract
If a percutaneous transhepatic biliary catheter has not been placed preoperatively, other techniques are utilized to
place the Silastic transhepatic biliary stent. After the proximal biliary segment has been dissected and the stricture resected, the biliary tree can be instrumented with a Randall stone forceps passed up to within 1 cm or 2 cm of Glisson’s
capsule. The forceps are then forced out through Glisson’s capsule and a Silastic stent is sutured to its end. By withdrawing the Randall stone forceps, the Silastic stent is placed (9). An alternative is to pass an elongated Bakes dilator
up through the intrahepatic biliary tree out through the superior surface of the liver and then to suture the Silastic stent
to the olive tip (10). A hole drilled in the olive tip aids in securing the stent to the instrument. By whatever means,
once the transhepatic Silastic biliary stent has been placed, it is positioned so that the portion of the stent with multiple side holes resides within the liver and in that portion which is to be placed within the Rouxen-Y loop. The part of the stent that
emanates from the superior surface
of the liver obviously contains
no side holes (8).
Randall
stone
forceps
Silastic
biliary
stent
10
9
Bakes
dilator
Resection of a Benign Bile Duct Stricture with Reconstruction Utilizing a Hepaticojejunostomy 49
A Roux-en-Y jejunal loop 60 cm in length is constructed. A
proximal loop of jejunum just distal to the ligament of
Treitz is divided with a GIA stapler. The small
bowel mesentery is divided down
towards its root (11).
11
Transverse
colon
Middle colic
vessels
Duodenum
Ligament
of Treitz
Proximal
jejunum
Divided
mesentery
Distal
jejumum
50 Atlas of Gastrointestinal Surgery: Gall Bladder and Biliary Tract
12
Proximal
jejunum
jejunojejunostomy. This is carried out 60 cm distal to the end
of the Roux-en-Y loop. The anastomosis is constructed with an
inner continuous layer of 3-0 synthetic absorbable material and
an outer interrupted layer of 3-0 silks. After the posterior row of
interrupted sutures has been placed, the staple line from the end of
the proximal jejunum is removed with the electrocautery (12).
Outer layer of
posterior row of
end-to-side
jejunojejunostomy
Enteric continuity is reestablished with an end-to-side
An enterotomy is made along the antimesenteric
border in the Roux-en-Y loop at the point of the
end-to-side anastomosis. The posterior layer is
carried out with 3-0 synthetic absorbable
material placed in a continuous over-and-over
locking fashion (13).
Enterotomy
13
Inner layer of
posterior row
Linen-shod
clamps
Resection of a Benign Bile Duct Stricture with Reconstruction Utilizing a Hepaticojejunostomy 51
This suture is continued as the inner anterior
layer and is placed using a continuous Connell
suture (14). The outer anterior layer is completed with interrupted 3-0 silk sutures (15).
The defect in the small bowel mesentery is
closed with either interrupted 4-0 silks as pictured here (16) or with a continuous 4-0
suture. The staple line at the end of the jejunal
Roux-en-Y loop is closed with a series of interrupted 3-0 silk Lembert sutures.
14
Inner layer of
anterior row
Outer layer of
anterior row
Closure of
mesentery
15
16