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Chapter 27 / Biliary Malignancies 341
should serve as contraindications for reasonable attempts at curative resec-
tion. Intraoperative ultrasound is a useful tool to further delineate spatial
relationships between the tumor, liver, and surrounding hilar structures.
Tumors limited to the mucosa (T1a) can be treated suciently with
cholecystectomy alone. Patients with deeper invasion require en bloc par-
tial hepatectomy (wedge resection of adjacent liver for T1b tumors; seg-
ment IVb+V resection for T2-3 tumors) with regional subhilar periportal
lymphadenectomy. Resection of the extrahepatic bile ducts followed by
reconstruction with hepaticojejunostomy should be reserved for tumors
that extend into the hepatic or common bile duct. Tumor invasion of the
right hepatic duct and/or right hepatic artery is not a contraindication to
operative resection, which requires an extended right hepatectomy in this
circumstance.
Appreciating the extent (size, multifocality, major vascular involve-
ment) of intrahepatic bile duct cancer on preoperative imaging and intra-
operative ultrasound is crucial for planning hepatic resections for this
disease. ese tumors frequently arise from the segment IV ducts and
involve the central liver inow anatomy. ree phenotypes of intrahepatic
cholangiocarcinoma have been described: periductal inltrating, mass-
forming, and intraductal/papillary. Usually large, these tumors often
require a major hepatectomy that warrants serious preoperative con-
sideration for the size and status of the future liver remnant (described
above under preoperative planning). Proper incision and exposure are
essential elements of a safe hepatectomy. Hemostatic hepatic parenchy-
mal transection has been aided by several energy devices, including the
ultrasonic aspirator, saline-linked cautery, bipolar electrocoagulation,
and ultrasonic scalpel. A solitary tumor located peripherally, especially
within an anterior segment, is often amenable to a safe laparoscopic tech-
nique that focuses on segmental anatomy for optimal tumor clearance.
e spatial relationship of the tumor to the sectoral bile ducts and hepatic
ducts needs to considered in all cases. A periductal inltrating phenotype
of a tumor with involvement of the left, right, or common hepatic ducts
will require extrahepatic biliary resection often with the need for biliary
reconstruction.
e Bismuth-Corlette classication scheme provides a rudimentary
guide for planning operative resection for hilar cholangiocarcinoma. Type I
tumors without involvement of the right hepatic artery can be treated with
resection of the entire extrahepatic biliary tree (without hepatectomy), sub-
hilar lymphadenectomy, and bilateral cholangiojejunostomy. Since biliary
branches of the hepatic caudate are involved in most cases of type II-III hilar
cholangiocarcinoma, caudate resection en bloc with a major hepatectomy
and extrahepatic bile duct resection is indicated for these tumors. Type IIIa
tumors, which may encase the right hepatic artery, are approached with
an extended right hepatectomy or formal right trisectionectomy with cau-
date resection. In the absence of right hepatic artery involvement, type IIIb
tumors are resected with extrahepatic bile duct excision, left hepatectomy,
and caudate resection. e nal bile duct margin status, both proximally
and distally, should be assessed intraoperatively with frozen section histopa-
thology. Sub- and perihilar lymphadenectomy should be considered routine
for all operations. Kocherization of the duodenum and head of the pancreas
during early exploration permits examination of the retropancreatic and
aortocaval spaces to exclude advanced levels of lymph node metastases and
limited opportunity for long-term benet following operative resection.
Pancreatoduodenectomy for periampullary carcinoma has been
described extensively throughout this text. Understanding the longitudi-
nally spreading nature of cholangiocarcinoma, most surgeons recommend
Section III / Biliary342
a high transection of the common hepatic duct in patients with distal bile
duct cancer. e proximal hepatic duct margin should be analyzed intraop-
eratively to ensure tumor clearance.
PREVENTION AND TREATMENT OF POSTOPERATIVE
COMPLICATIONS
Postoperative uid collections after hepatectomy are usually related to
either bleeding or bile leaks from the transected liver surface. Intraoperative
transcystic leak tests after hepatectomy can be performed, but have not
been shown to aect the incidence of postoperative bile leaks. Leaks from
small biliary radicals rarely require intervention; however, 8% of all hepa-
tectomies result in bile leaks from segmental ducts requiring percutaneous
drainage. Percutaneous drainage alone will treat the majority of perihepatic
uid collections. Persistent bile leaks after percutaneous drainage should
raise suspicion for a stricture of the native distal bile ducts or biliary–
enteric anastomosis. In these situations, endoscopic or percutaneous bili-
ary stenting may be necessary for resolution.
e reported association between deep organ space infection after
hepatectomy and biliary–enteric anastomosis encourages judicious opera-
tive drain placement. Decompression of the biliary–enteric anastomosis
with transhepatic stenting has been utilized by some surgeons to decrease
the incidence of infectious complications after hepatectomy.
e risk of postoperative hepatic failure after major hepatectomy is
related to the volume and quality of the functional liver remnant. Factors
that predispose patients to postoperative hepatic failure include age,
gender, diabetes mellitus, fatty liver disease, operative blood loss, small
liver remnant (<20% normal liver volume, <40% cirrhotic liver volume),
cholestasis, and postoperative infection. Preoperative factors can be
addressed with techniques to improve the functional liver remnant, for
example, biliary drainage and portal vein embolization. Postoperative
liver failure must be addressed promptly in the postoperative period with
drainage of perihepatic uid collections and appropriate treatment of
infection.
OUTCOMES
Stage-dependent survival after resection for gallbladder adenocarcinoma
is summarized in Figure 27.4. Median survival for stage IV gallbladder can-
cer is less than 6 months; thus, operative intervention, even with palliative
intent, for this stage of disease is never advocated. Simple cholecystectomy
for pathologically staged T1a cancer results in cure in most cases, whereas
more advanced stages of disease requiring extensive operations for tumor
clearance lend themselves to long-term survival infrequently. e role of
adjuvant therapy for gallbladder adenocarcinoma remains unclear. Past
studies of 5-uorouracil or gemcitabine with or without external beam
radiotherapy failed to show a benet in long-term survival; however, the
addition of cisplatin to gemcitabine has improved treatment response rates
for unresectable biliary tract cancers considerably. Future collaborative tri-
als are necessary to study the benets of adjuvant platinum-based chemo-
therapy for bile duct cancer.
Aggressive operations for hilar cholangiocarcinoma have been
associated with major postoperative complications and mortality. But,
improvements in operative technique along with better patient selec-
tion and avoidance of postoperative hepatic failure have decreased
postoperative morbidity and mortality substantially over the past two
decades. Long-term survival is realized only for patients who undergo
Chapter 27 / Biliary Malignancies 343
an R0 resection and do not carry lymph node metastases. Orthotopic
liver transplantation for hilar cholangiocarcinoma can achieve excellent
long-term outcomes for highly selected patients (i.e., no lymph node or
distant metastases) who demonstrate no evidence of disease progression
with neoadjuvant chemoradiotherapy. Liver transplant for cholangiocar-
cinoma is only performed in select centers with extremely close clinical
selection criteria.
Patients with unresectable, locally advanced hilar tumors but without
evidence of widespread disease may be candidates for palliative radiation
therapy. A combination of stereotactic external beam radiation (5,000 to
6,000 cGy) with or without intraductal iridium-192 (2,000 cGy) delivered
percutaneously or endoscopically can be applied. Intraluminal (either
endoscopic or transhepatic) photodynamic therapy has been utilized for
unresectable hilar cholangiocarcinoma. is two-step procedure involves
systemic administration of a photosensitizer followed by direct illumina-
tion via cholangioscopy, which activates the compound causing local tumor
cell death. Two randomized studies in patients with unresectable cholan-
giocarcinoma suggested improved survival with biliary stenting combined
with photodynamic therapy compared with biliary stenting alone, but the
improved survival observed with photodynamic therapy is likely related to
better biliary decompression and avoidance of early segmental duct isola-
tion and subsequent cholangitis, rather than any signicant reduction in
tumor burden.
Several pathologic features of intrahepatic cholangiocarcinoma
have adverse eects on prognosis even after complete resection. Lymph
node metastases, multifocality, and major vascular invasion all have nega-
tive impact on survival. Liver transplantation has been utilized for highly
selected patients with technically unresectable tumors conned to the liver.
Transarterial chemoembolization and radioembolization can be oered to
patients with unresectable disease in an attempt to slow disease progres-
sion and possibly improve survival.
0
Dx 1 Y2 Y3 Y4 Y
IVA/IVB
IIIA/IIIB
II
I
Stage 0
5 Y
20
40
60
80
100
FIGURE 27.4 Overall 5-year survival for resected gallbladder adenocarcinoma, accord-
ing to AJCC seventh edition cancer stage. (Figure borrowed from Lillemoe K, Jarnagin
WR (eds.). Hepatobiliary and pancreatic surgery. Philadelphia, PA: Lippincott Williams &
Wilkins, 2013.)
Section III / Biliary344
CONCLUSION
Enhanced radiologic imaging and greater understanding of malignancies of
the biliary tract have permitted improved operative outcomes over the past
few decades. Progress in these two areas has allowed better patient selec-
tion, preoperative preparation of the future liver remnant, and techniques
to treat bile duct cancer from a surgical standpoint. Even in the modern
era, highly eective systemic agents for cholangiocarcinoma are lacking,
which leaves a large therapeutic gap for patients with advanced stages of
disease. One of the main goals of treating patients with bile duct cancer is
palliation from biliary obstruction, which can be accomplished endoscopi-
cally, percutaneously, or operatively. With recent improvements in chemo-
therapy, endoluminal therapy, and brachyradiotherapy, a multidisciplinary
approach toward treating bile duct cancer should be advocated in order to
achieve optimal individualized treatments for patients.
Suggested Readings
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Endo I, House MG, Klimstra D, et al. Clinical signicance of intraoperative bile
duct margin assessment for hilar cholangiocarcinoma. Ann Surg Oncol 2008,
15(8):2104–2112.
Farges O, Belghiti J, Kianmanesh R, et al. Portal vein embolization before right hepa-
tectomy: prospective clinical trial. Ann Surg 2003; 237:208–217.
Jarnagin WR, Fong Y, DeMatteo RP, et al. Staging, resectability, and outcome in 225
patients with hilar cholangiocarcinoma. Ann Surg 2001;234:507–519.
Kawasaki S, Imamura H, Kobayashi A. Results of surgical resection for patients with
hilar bile duct cancer: application of extended hepatectomy after biliary drainage
and hemihepatic portal vein embolization. Ann Surg 2003;238:84–92.
Kennedy TJ, Yopp A, Qin Y, et al. Role of preoperative biliary drainage of liver rem-
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345
Minimally invasive biliary surgery is indicated in only a few isolated
complex biliary disease processes when technical expertise is available.
Historically and currently, the vast majority of biliary surgery is performed
through an open approach. However, the benets of laparoscopic surgery
have been established in numerous other areas of general surgery includ-
ing cholecystectomy, gastric bypass, and colectomy. Currently, a paucity of
data exists regarding the role of minimally invasive biliary surgery. rough
the improvement of surgical skill (experience and fellowship training) and
technology (optics, robotics, surgical staplers, and tissue-sealing devices),
surgeons have begun to challenge the standard of care in biliary surgery.
In order to avoid overlap, this chapter focuses primarily on laparoscopic
Roux-en-Y hepaticojejunostomy as the preferred biliary–enteric recon-
struction for the treatment of biliary disease.
PREOPERATIVE CONSIDERATIONS
Preoperative considerations focus primarily on patient variables that aect
minimally invasive surgery and preparation of the patient for surgery.
Patient variables to consider include comorbid conditions, past surgical
history (especially abdominal surgery), body habitus, and hepatoduode-
nal ligament anatomy. Comorbid conditions play a role in laparoscopic
approach primarily as a function of length of anesthetic time and ability to
clear carbon dioxide from the pneumoperitoneum. Patients with advanced
cardiopulmonary disease are particularly fragile if the length of anesthetic
time is excessive. is may negate the typical benets of the laparoscopic
approach. As a surgeon gains experience, operative times typically decrease
dramatically, yet the learning curve in complex biliary surgery is unknown.
Airway pathology (obstructive sleep apnea) and pulmonary disease (chronic
obstructive pulmonary disease) can be exacerbated as a result of prolonged
anesthetic and subsequent insuation with carbon dioxide. Nearly 100%
of patients who possess a body mass index (BMI) of greater than 45 have
obstructive sleep apnea (with or without documented sleep studies), and
patients with home oxygen requirements or room air arterial CO
2
concen-
tration of greater than 44mmHg should be identied as high risk prior to
entering the operative theater. A history of portal hypertension or cirrhosis
can be a major deterrent regardless of approach.
Past surgical history is a major component for surgeon decision mak-
ing in terms of peritoneal access, port placement, the ability to perform the
jejunojejunostomy, and whether the Roux limb will reach the porta hepatis
for bile duct reconstruction. History taking and examination are critical
to determine previous abdominal operations and location of concurrent
cicatrices. Ventral hernia repair with mesh should also be specically
determined as peritoneal access and contamination of synthetic mesh with
bile can create new infectious problems. More extensive open abdominal
Minimally Invasive Biliary
Surgery
Eugene P. Ceppa
28
Section III / Biliary346
operations tend to have more robust adhesions around the small bowel,
which can either prevent formation of an adequate Roux limb or increase
operative times for the required enterolysis.
Body habitus is not a contraindication to laparoscopy but deters some
surgeons for multiple reasons. Larger patients (BMI > 35) require longer
instruments; thus, reach to the porta hepatis can be dicult. Abdominal
wall tension on laparoscopic instruments can place undue stress to long,
thin instruments and can either limit the ability to use some necessary
instruments or damage them beyond functional use. Mobilization of the
hepatic exure and a Kocher maneuver are made more dicult when the
transverse mesocolon and omentum contain more fat and organs are larger
in size overall; once mobilized, the hepatic exure and the retroperitoneum
lateral to the duodenum can be more dicult to retract for exposure pur-
poses when fatty or large. Finally, super morbidly obese (BMI > 50) patients
typically have engorged livers as a result of fatty liver disease and are prone
to lacerations (hemorrhage within the operative eld signicantly impairs
image brightness) and fractures leading to further surgery to correct the
problem. ese patients should be considered for a preoperative liquid diet
with protein supplementation (7 days prior) to diminish the water weight
of the liver resulting in a temporary reduction in liver size to optimize the
intraoperative exposure and minimize surrounding tissue injury.
Mastering the patient’s preoperative diagnostic imaging can make
intraoperative decision making clearer. Cholangiography provides an intra-
luminal roadmap of the biliary tree. Identication of cystic duct or cystic
duct clips can be performed safely and provide intraoperative details about
the location of the bile duct. Also, knowledge of bile duct anomalies helps
avoid injury when they are expected prior to surgery. Cross-sectional imag-
ing with arterial and venous phases assists in determining the location of
the hepatic arterial branches (specically if the right hepatic artery tra-
verses anterior to or passes posterior to the common hepatic duct to avoid
inadvertent injury or ligation). Replaced right or completely replaced com-
mon hepatic artery branches should be identied with imaging to avoid
injury during mobilization of the bile duct. Portal vein, superior mesenteric
vein, and splenic vein thrombosis should be sought out prior to surgery as
collateral veins can make the hepatoduodenal ligament dissection treach-
erous. Finally, a large, pathologically dilated bile duct can be easily seen on
diagnostic imaging, and some surgeons will only attempt a laparoscopic
hepaticojejunostomy on dilated bile ducts as a tenet of patient selection.
Patients with complex biliary disease commonly have other medical
issues that require treatment prior to surgery. Preoperative biliary obstruc-
tion exposes the patient to the eects of jaundice, bactibilia, and external
manipulation of the biliary tree (endoscopic or transhepatic). When infection
is present in the form of cholangitis or biloma, antibiotics are indicated, and
treatment of the obstruction with biliary endoprosthesis or percutaneous bil-
iary drains and/or percutaneous peritoneal drains is required for source con-
trol. Patients with infection or biliary insensible losses may be malnourished,
may be dehydrated, possess electrolyte abnormalities, and are decient in
vitamin K altering coagulation parameters. All of these factors should be cor-
rected prior to surgery to minimize postoperative complications.
OPERATIVE INDICATIONS AND TECHNICAL TIPS
Indications for hepaticojejunostomy are listed in Table 28.1. Biliary obstruc-
tion secondary to benign and malignant strictures is the primary indica-
tion for hepaticojejunostomy. Benign complex biliary disease includes
iatrogenic biliary stricture, choledochal cysts, chronic
p
ancreatitis, Mirizzi
Chapter 28 / Minimally Invasive Biliary Surgery 347
syndrome, and traumatic bile duct injuries. Choledocholithiasis and mini-
mally invasive treatment thereof can be found in Chapter 25 (common bile
duct exploration). Indications for treatment of malignant biliary strictures
include extrahepatic bile duct resection and reconstruction of cholangio-
carcinoma (Bismuth II) or palliation of periampullary tumors (pancreatic
adenocarcinoma, distal cholangiocarcinoma, duodenal adenocarcinoma,
and ampullary adenocarcinoma) and portal lymphadenopathy resulting
from metastasis of secondary malignant tumors. Periampullary tumor
treatment with curative intent via a laparoscopic pancreaticoduodenec-
tomy can be found in Chapter 8 (laparoscopic pancreatic surgery).
Most studies indicate that a Roux-en-Y hepaticojejunostomy is the saf-
est and most reproducible method of biliary–enteric reconstruction possess-
ing the best long-term patency rate. e critical skill set for this procedure
is intracorporeal suturing using laparoscopic needle drivers and graspers.
e following are the critical steps toward biliary–enteric reconstruction:
1. Patient position with both arms out is suitable.
2. Port placement can vary among surgeons, but Figure 28.1 demonstrates
an accepted conguration. e ports consist of a 5 mm port in both the
right and left subcostal margins, a 12-mm right upper quadrant port
(surgeon’s primary port), and a 5- or 12-mm port in both the left upper
quadrant and umbilicus (primarily for the camera). A subxiphoid incision
can be made without a port for placement of a liver retractor.
3. To create the Roux limb, starting in the supine position is best. e liga-
ment of Treitz is identied at the base of the transverse mesocolon.
4. A window is created between the vasa recta of the small bowel, and the
small bowel is divided using a laparoscopic stapler with a 3.5-mm staple
load approximately 50cm distal to the ligament of Treitz.
5. Use the tissue-sealing device to divide the mesentery evenly in order not
to encroach on the arterial arcade on either side of the divided bowel
(optional). is maneuver provides a slightly longer reach to the bile duct
and avoids undue tension on the anastomosis. e bowel proximal to
the staple line is the alimentary limb; an additional 50cm of small bowel
distal to the staple line is measured and referred to as the Roux limb.
6. A side-to-side jejunojejunostomy is fashioned:
a. Two 3-0 absorbable stay sutures are placed 6 to 10cm apart.
b. Enterotomies are created with the cautery.
Indications for Biliary–Enteric Reconstruction
TABLE
28.1
Benign
Iatrogenic bile duct injury
Chronic pancreatitis
Choledochal cysts
Mirizzi syndrome
Traumatic bile duct injury
Malignant
Cholangiocarcinoma (mid–bile duct)
Pancreatic adenocarcinoma—palliative
Cholangiocarcinoma (distal)—palliative
Duodenal adenocarcinoma—palliative
Ampullary adenocarcinoma—palliative
Portal lymphadenopathy—palliative
Section III / Biliary348
c. An articulating 60-mm cartridge of a 2.5-mm staple load is intro-
duced into the bowel via the enterotomies. is load is generally
more hemostatic than is the typical 3.5-mm load used commonly for
bowel cases.
d. e bowel is manipulated so that the mesentery is outside the staple
load.
e. e anastomosis between the alimentary and Roux limbs is created
with the stapler.
f. e common enterostomy is oversewed with a 3-0 absorbable run-
ning suture.
g. e jejunojejunostomy mesenteric defect is closed with a running 2-0
nonabsorbable suture to prevent future internal hernias. Avoid full-
thickness bites across the bowel mesenteric edge that was previously
sealed with an energy device, which can lead to unnecessary hemor-
rhage, ischemia, or hematoma near the anastomosis. e subsequent
complications include bleeding, perforation, and obstruction postop-
eratively. Solely suture the peritoneum supercially together.
h. Visualize the Roux limb mesenteric edge, and travel down toward the
root of the mesentery to ensure the mesentery is not twisted (this is
worth double or triple checking as peripheral visualization is limited
during laparoscopic surgery).
i. Create a defect in the transverse mesocolon with the tissue-sealing
device to the right of the middle colic artery. Preserve the left space
in case a future pancreatic Roux limb is needed.
j. Mark the Roux limb staple line with a stitch or a Penrose drain/col-
ored tourniquet to make passing the bowel through the transverse
mesocolon defect easier (optional).
7. Mobilization of the common bile duct within the hepatoduodenal
ligament—mobilizing the hepatic exure of the colon and performing wide
Kocher maneuver should be used liberally to expose the porta hepatis:
X
5
12
5 – 12
5 – 12
5
*
FIGURE 28.1 Port site placement for laparoscopic Roux-en-Y hepaticojejunostomy.
*, Camera port; X, optional liver retractor.
Chapter 28 / Minimally Invasive Biliary Surgery 349
a. If no cholecystectomy has been performed previously, use the gall-
bladder to identify the cystic duct, and travel proximally toward the
common hepatic–bile duct junction. e gallbladder also provides
a useful “handle” (Fig. 28.2) for a lateral to medial approach when
dissecting the soft tissues of the hepatoduodenal ligament. Typically,
there is a station 12 lymph node just cephalad to the duodenum along
the lateral border of the ligament to mark the location of the distal
common bile duct.
b. Incise the peritoneum anteriorly to expose the bile duct and hepatic
arterial supply. e bile duct will be lateral to the proper hepatic
artery. Be mindful that the right hepatic artery travels anterior to the
common hepatic duct in 10% of patients.
c. Mobilize the ligament further by incising the peritoneum laterally
toward the inferior vena cava to open near the shared border of the
common bile duct and portal vein. is maneuver will allow for less
resistance when dissecting medially to laterally posterior to the bile
duct.
d. Encircle the bile duct with a vessel loop or Penrose drain; use metallic
clips to secure both tails together for retraction purposes.
e. Pass a right-angled instrument posterior to the bile duct, and use
the cautery to divide the bile duct. e cautery can be used to obtain
hemostasis at the 3 and 9 o’clock arterial supple at the cut edge of
the bile duct. e bile duct should bleed briskly; if it does not, then
consider dissecting the bile duct proximally to better perfused tissue.
f. If a biliary endoprosthesis or percutaneous biliary drain is across the
bile duct, either can be used to stent your anastomosis. Otherwise,
if it is cumbersome, stents can be removed as it may make the anas-
tomosis more dicult. If stenting the biliary–enteric anastomosis is
desired, the ideal situation is to place your own 12-Fr biliary stent
across the anastomosis after the posterior row has been completed.
FIGURE 28.2 The gallbladder (if in situ) provides a useful landmark and “handle” to distract
the bile duct laterally.
Section III / Biliary350
g. A laparoscopic bulldog clamp is commercially available and can be
used to clamp the proximal cut edge of the bile duct; in some cases,
this may allow for a slight dilatation of a smaller bile duct and mini-
mize biliary soilage of the peritoneum.
h. e distal bile duct should be oversewn or may be closed with a staple
(or clips if small).
8. Biliary–enteric anastomosis:
a. Some surgeons prefer the Trendelenburg position (head down) at the
time of an intracorporeal hand-sewn hepaticojejunostomy to take
tension o of the anastomosis by way of the small bowel mesentery
using gravity to bring the Roux limb closer. Reverse Trendelenburg
position is useful in obese patients by using gravity to retract the
hepatic exure away from the porta hepatis. e Roux limb is usu-
ally supported with a grasper from one of the assistant port sites in
either scenario.
b. For larger bile ducts, tie two separate 4-0 absorbable sutures together
leaving it double armed. Each suture is cut to a shorter length typically
15 to 20cm each in length but can be adjusted based on the size of the
bile duct. For small bile ducts, interrupted 4-0 absorbable sutures are
used for the posterior and anterior rows (Fig. 28.3).
c. An enterotomy is created on the anterior aspect (i.e., bowel side clos-
est to the camera) of the antimesenteric border of the Roux limb.
d. A stay suture is placed at 12 o’clock on the bile duct for retraction of
the anterior wall during creation of the posterior row.
e. e suture is introduced into the peritoneum; one arm is passed
outside-in on the bowel and the other on the bile duct (starting at
3 o’clock).
f. e posterior row is created rst by suturing inside out on the bowel
then outside-in on the bile duct. Special attention is necessary during
the rst bite with the suture as most leaks will occur posteriorly on the
bile duct side after the initial anchoring of the double-armed suture.
g. Upon completion of the posterior row, a bulldog clamp is placed on
the remainder of the posterior row stitch to maintain tension prevent-
ing unraveling of the posterior row.
FIGURE 28.3 The posterior row of absorbable sutures is placed with knots on the inside of
the anastomosis to facilitate visualization of the knots being tied.