cystic duct [27]. The efficacy of these intraopera­tive tests remains unclear. One randomized trial of 103 consecutive patients undergoing hepatic resection without biliary enteric anastomosis showed no difference in bile leaks when isotonic saline was injected through the cystic duct [28]. Another report indicated decreased incidence of bile leaks with indocyanine green and fluores­cent cholangiography in 102 randomized patients [29]. Finally, a recent report of 223 patients, half of which underwent an intraoperative air leak test by introduction of air through a transcystic chol­angiogram catheter, demonstrated a reduction in biliary leaks from 10 to 1.9 % [19]. Further vali­dation of various techniques and comparative tri­als will be required to confirm optimal.

The role of postoperative drains after hepatic re­section remains controversial. Proponents claim that drains are infrequently the source of mor­bidity and, if appropriately positioned and of ap­propriate type, control biliary leaks. Conversely, opponents claim drains are unnecessary given the low frequency of biliary leaks and can cause morbidity, specifically surgical site infection, bil­iary erosion, and leak or inadequate biliary leak control if present. Many centers place drains pro­phylactically at the parenchymal transection site. Some evidence suggests that routine placement of drains is unnecessary and may be associated with increased infection [30, 31]. In the larg­est series, an audit of over 1000 liver resections failed to demonstrate increased morbidity in the 80 % of patients who were not drained. Intraop­erative drains were placed if patients underwent a simultaneous thoracotomy, an uncontrolled bile leak was encountered, bilioenteric anastomosis was performed, or if the field was infected. A metaanalysis did not demonstrate a statistically significant difference in rate of biliary fistula, reoperation, intraabdominal collections requir­ing aspiration or drainage, with or without an operatively placed drain [32]. Minor liver resec­tions are drained rarely. Biliary reconstruction

(Fig. 18.1). Identification of biliary dilatation and assessment for concomitant vascular injury are also important.

If bile is present in the drain, a fistulogram can reveal the source of the bile leak. Injection of contrast through the drain and subsequent opaci­fication of the communicating area of the biliary tract allows definition of anatomy and guides subsequent management (Fig. 18.1c). Fistulogra­phy also allows assessment of the adjacent area or collection and whether or not biliary obstruc­tion distal to the site of leakage exists.

of segmental bile duct injuries, a hepaticojeju­nostomy is constructed in an end to side, duct to mucosa fashion. In rare cases where it is not possible to perform a duct to mucosa anastomo­sis, a mucosal patch with transhepatic drain may be considered, although some reports indicate complications including separation of the jejunal limb and obstruction of adjacent secondary bili­ary radicles by the mucosal patch [43].

and perform intraoperative cholangiography if uncertain.

tients.

ary injury is identified.

Reoperative surgery is a perfect setup for biliary injury as scarred hilum as well as extensive adhe­sions make identification of segmental anatomy difficult. In addition, excessive blood loss, which is considered a risk factor for biliary injury [2, 7], can make the procedure even more challenging by impairing visualization and by making proper identification of hilar structures difficult.