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62 Atlas of Gastrointestinal Surgery: Gall Bladder and Biliary Tract
Generally, frozen section margins are reasonably accurate. These tumors are often fibrotic and, early in our experience,
frozen sections were inaccurate. However, with more experience, the accuracy has improved substantially. When all three
margins are negative, the biliary reconstruction can proceed. Often there are no obvious lymph nodes that are obtained
with dissection of the porta hepatis. Most lymph nodes are distal at the junction of the common duct and duodenum.
These are rarely involved with tumor. If lymph nodes are visible, however, they should be included with the dissection of
the proximal biliary segment.
Both the right and left hepatic ducts are intubated with Silastic transhepatic biliary stents. The percutaneous transhepatic biliary catheters that were previously placed are advanced through the chest wall into the abdominal cavity. In order
not to lose the tract if one of the catheters should break or become dislodged, guidewires are placed through the percutaneous rigid catheters. A 16 French Silastic biliary stent is then slipped over the guidewire, and over the transhepatic biliary catheter as it emanates out through the porta hepatis. It is sutured in place with 2-0 silk mattress sutures. The rigid
biliary catheters are then pulled out through the superior surface of the liver, thus positioning the Silastic stents in their
proper position (8).
8
Guidewire
Percutaneous
catheter
Silastic
biliary
stent
Coudé
catheter
Resection of a Proximal Cholangiocarcinoma (Klatskin tumor) with Reconstruction via Bilateral Hepaticojejunostomies 63
That portion of the Silastic stent that contains multiple side holes (40% of the stent) is positioned
intrahepatically and outside the hilum of the liver (9). Obviously that portion of the stent that emanates
out through the superior surface of the liver contains no side holes. The division point of the right hepatic duct in the liver hilum is often close to the bifurcation of the anterior and posterior segments. If this
is the case, the spur is divided (10) and one anastomosis is performed. Occasionally, to get a negative margin, one will have to extend up and resect the segmental bifurcation on the right, leaving separate anterior and posterior segmental ducts. Since only one will be intubated with a
Silastic stent, a third Silastic stent may be placed at this time.
Silastic
biliary
stent
Dividing
spur of r.
hepatic
duct
Silastic
biliary
stent
10
9
L. hepatic
duct
Hepatic a.
Portal v.
64 Atlas of Gastrointestinal Surgery: Gall Bladder and Biliary Tract
A Roux-en-Y jejunal loop 60 cm in length is then constructed, as
demonstrated previously. The Roux-en-Y loop is brought up into the
right upper quadrant in a retrocolic route, on top of the second and
third portions of the duodenum through the bare area in the transverse mesocolon. The anastomosis is performed in one layer, using
interrupted 4-0 synthetic absorbable sutures. The entire back row
is placed prior to securing any of the sutures. Each suture passes first
through the jejunal loop, and then through the duct from the outside in (11). Thus, the knots of the posterior row will be placed on
the inside. Since we utilize synthetic absorbable material, however, this
is of no long-term concern. Each suture is individually placed in a hemo-
11
stat, and the hemostats are placed in order on a long clamp (12).
Roux-en-Y jejunal loop
12
Posterior
rows of
anastomoses
Resection of a Proximal Cholangiocarcinoma (Klatskin tumor) with Reconstruction via Bilateral Hepaticojejunostomies 65
Once the posterior row of each hepaticojejunostomy has
been placed, the sutures are secured. Bilateral enterotomies
Posterior
rows of
anastomoses
are made adjacent to the posterior row of sutures using the
electrocautery (13).
Silastic
biliary
stents
14
Enterotomies
13
The posterior row of sutures, except for the two
end sutures, is then divided, and the Silastic
stents are placed in the Roux-en-Y loop via each
enterotomy (14).
66 Atlas of Gastrointestinal Surgery: Gall Bladder and Biliary Tract
15
Roux-en-Y
jejunal loop
Anterior
rows of
anastomoses
16
Each interrupted 4-0 synthetic absorbable suture is placed for the anterior layer of both hepaticojejunostomies, before securing the sutures (15). These sutures are simple sutures placed through and through the jejunum and then through and through the
duct (16). Once all sutures of the anterior row of both hepaticojejunostomies have been placed, they are tied.
Once the anterior rows of both hepaticojejunostomies have been secured, the sutures are cut. The Roux-en-Y jejunal
loop may be sutured to tissues on the undersurface of the liver with interrupted 3-0 silks to ensure that there is no tension on the anastomosis. With a Roux-en-Y loop 60 cm in length, however, it generally rests comfortably under the liver
at the anastomosis, and fixation may not be necessary.
Resection of a Proximal Cholangiocarcinoma (Klatskin tumor) with Reconstruction via Bilateral Hepaticojejunostomies 67
Roux-en-Y
jejunal loop
Silastic
biliary
stents
Hepaticojejunostomies
Transverse
mesocolon tacked
to jejunal loop
Transverse colon
17
End-to-side
jejunojejunostomy
The Roux-en-Y loop is sutured to the rent in the transverse mesocolon with interrupted 4-0 silks to prevent herniation
of small bowel (17). Each Silastic transhepatic biliary stent is brought out through a separate stab wound in the right and
left upper quadrants, and sutured to the skin with 5-0 stainless steel wire. The stents are connected to allow bile-bag
68 Atlas of Gastrointestinal Surgery: Gall Bladder and Biliary Tract
drainage through gravity. The egress of each stent on the superior surface of the liver is drained with a closed suction Silastic
drain brought out through separate stab wounds in the right and left upper quadrants. The bilateral hepaticojejunostomies
are drained with a closed suction Silastic drain brought out through a stab wound in the mid-abdomen. The stents are left
to allow gravity drainage for five days, at which time cholangiography is performed. If there are no leaks from the superior surface of the liver or at the anastomosis, the tubes are internalized by placing stopcocks or heparin locks on the ends
of the stents.
The patients are taught to irrigate the stents twice a day with 20 mL of saline. Adjuvant therapy has not clearly been
identified to be of benefit in these patients. However, we have had no long-term survivors who have not received radiotherapy. We thus generally deliver 5,000 rad of external beam radiotherapy to the tumor bed postoperatively. When this
has been completed, the patients can be re-admitted and iridium 192 seeds lowered down through the bilateral transhepatic biliary stents and left in place for approximately 48 hours, to boost the radiation dosage an additional 2,000 rads.
The transhepatic Silastic biliary stents are generally left in permanently. The stents are changed every 3 or 4 months as an
outpatient procedure. This is carried out under fluoroscopy by placing a guidewire down through the old stent into the
Roux-en-Y loop. The old stent is then removed, leaving the guidewire in place. A new stent is easily slipped in place over
the guidewire and then the guidewire removed. The stents are left in long-term because, even though substantial prolongation of survival is achieved with this operative procedure, many patients are not cured and, eventually, the tumor will
recur locally. If the Silastic stents are removed, biliary obstruction will recur. However, if a patient survives for three years,
and there is no cholangiographic evidence of recurrent tumor, the Silastic stents may be removed.
Resection of a Proximal
Cholangiocarcinoma with Hepatic
Lobectomy and Reconstruction with
a Hepaticojejunostomy
Operative Indications:
Patients with proximal cholangiocarcinomas will frequently have
tumor extension up into one or the
other lobe from the bifurcation
(1). In most instances it will be on
the right. In addition, it is not infrequent in such instances to have one
branch of the portal vein or one branch of
the hepatic artery on the involved side
encased or occluded by tumor. Such patients may
still be resectable if hepatic lobectomy is added to
1
Tumor extending
into the left lobe
of liver
Percutaneous
catheters
Common duct
Cystic a.
and duct
resection of the bifurcation and extrahepatic biliary tree.
One is aware of this possibility prior to laparotomy because
of preoperative cholangiographic and three-dimensional CT
scan findings.
70 Atlas of Gastrointestinal Surgery: Gall Bladder and Biliary Tract
Operative Technique:
The patient is explored through a right subcostal incision, often extended up to the
xiphoid in the midline, or over to the left side of the abdomen as a left subcostal extension. It is particularly important that these patients preoperatively have percutaneous transhepatic biliary catheters inserted bilaterally. The initial operative procedure is as described
for resection of a proximal cholangiocarcinoma without hepatic lobectomy.
The gall bladder is mobilized to improve
exposure of the bifurcation, and the
distal common duct is divided (2)
so that the proximal biliary segment can be reflected cephalad to facilitate bifurcation
dissection.
Tumor involving
bifurcation
Choledochotomy
Gall bladder
fossa
2
Mobilized
gall bladder
Percutaneous
biliary
catheters
Resection of Proximal Cholangiocarcinoma with Hepatic Lobectomy and Reconstruction with a Hepaticojejunostomy 71
Once the hepatic duct bifurcation has been mobilized and dissected off
the bifurcation of the portal vein and the hepatic artery (3), it is seen
that the tumor extends well up into the left lobe of the liver, probably also involving the left branch of the hepatic artery
and portal vein. On the right, however,
normal hepatic duct can be identified by palpating the percutaneous biliary catheter above the
tumor at the bifurcation.
3
R. and L.
hepatic aa.
Portal v.
Proximal
common duct
L. hepatic duct
Oversewn distal
common duct
R. hepatic duct
Tumor involving
hepatic duct
bifurcation
L. hepatic duct
Distal
common
duct
The right hepatic duct is divided (4) and the biliary catheter exposed
and extracted. At this point, a frozen section should be taken of the
right hepatic duct margin, and the distal common duct margin, to
ensure that both of these margins are negative.
Portal v. bifurcation
R, and L. hepatic aa.
4