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Bilioenteric Anastomoses
7
procedures that suffer stenosis. Among malignant indications are
cholangiocarcinoma and gallbladder carcinoma that infiltrates the common
bile duct, and is considered as a final step for palliative treatment. [47]
End-to-
side anastomoses are preferred over side-to-side, because the latter cannot
eliminate the risk of tumor ingrowth and obliteration of the anastomoses. [37]
Laparoscopic approach has also been proven to be a safe procedure. [48]
The
main contraindication for this technique is a short life expectancy (< 6
months).
Intrahepatic Anastomoses
Hepaticojejunostomy (Hepp-Couinaud)
This technique was first described in 1956 by Hepp and Couinaud as an
approach to the extrahepatic course of the left hepatic bile duct. [49] This
technique is also known as segment 3 hepatojejunostomy or B3
cholangiojejunostomy. [50] The most common indication are benign strictures,
especially iatrogenic bile duct injuries. It is particularly useful in high
strictures (benign or malignant) just below the confluence of the left and right
hepatic duct. [51] Hepp-Couinaud approach in bile duct injury is the most
frequent type of reconstruction technique performed.
It has the advantage of
allowing anastomoses over adequate tissue to ensure a high quality
anastomoses. Contraindications for this procedure are the presence of an
atrophic left lobe, a percentage of hepatic parenchyma to be drained less than
30% or less than two segments and presence of portal hypertension. [52-53] It
is a BEA that provides the best outcome and follow-up results.
Cholangiojejunostomy (Longmire-Sanford)
It was described in 1949 by Longmire and Sanford as anastomoses to bile
duct of segment II/III. This technique requires partial resection of segment III
to expose dilated intrahepatic ducts and perform anastomoses to a Roux-en-Y
jejunal loop. [55] The main indication for this procedure is proximal malignant
obstruction of the biliary tract as a palliative treatment. The main
complications of this technique are bleeding and dysfunction of the
anastomoses. Less invasive maneuvers are preferred, such as percutaneous
trans-hepatic biliary drainage. This type of procedure is now rarely performed
due to better palliative procedures with less morbidity.
Miguel Ángel Mercado and Julio Alfaro Varela
8
Techniques
The main objective of all BEA techniques is to accomplish adequate
biliary outflow into the gastrointestinal tract. Several principles must be
achieved to obtain a high quality anastomoses: [56]
Tension free anastomoses
Well vascularized
Widely patent anastomoses
Mucosa-to-Mucosa
Anastomoses that drain all parts of the liver
In the present chapter we will discuss the most frequently performed
bilioenteric anastomoses; the technical aspects of Roux-en-Y anastomosis will
not be mentioned with detail.
Type of Suture
The types of sutures utilized are important for adequate functioning of the
anastomoses. The ideal suture is hydrolysable monofilament absorbable 4-0 or
5-0. Multiple knots are avoided and should be placed outside the lumen to
prevent sludge formation and bile stasis. Silk and Catgut are not recommended
due to intense inflammatory response generated. Generally, anastomoses are
monolayer with interrupted stitches, but a continuous suture can be used if the
anastomosis is wide or according to the surgeon’s preference.
Recommended sutures:
Polyglicolic acid
Polydioxanone
Polypropylene monofilament
Polyglecaprone 25
Bilioenteric Anastomoses
9
Cholecystojejunostomy (Open Technique)
Incisions
Different types of incisions may be used to explore the abdomen. A right
subcostal incision with or without a vertical extension is an excellent option
(Hockey stick). A bilateral subcostal incision (Chevron) can also be used or a
midline incision. (Figure 1).
Figure 1. Types of incisions.
Surgical Aspects
Once the abdominal cavity has been reached, the surgeon must be sure
that the cystic duct insertion is at least 1 cm away from the tumor and that the
cystic duct is patent. The Gallbladder is left in situ and the body is used for the
anastomosis. A simple jejunal loop that reaches the sub-hepatic space in an
easy and tension free manner is used, or if the surgeon’s preference is a Roux-
en-Y jejunal limb is used and passed in a retrocolic or antecolic manner. The
jejunum is approximated to the gallbladder using a posterior row of interrupted
absorbable sutures (3-0). The body of the gallbladder is opened and the
incision is prolonged as much as possible (at least 2-3 cm).
The anti-mesenteric border of the jejunum is opened in a parallel manner,
but shorter. Full thickness of the gallbladder and jejunal wall is included in the
anastomoses, using continuous absorbable sutures (3-0 or 4-0). The
Miguel Ángel Mercado and Julio Alfaro Varela
10
anastomoses begin in the middle (posterior wall) and runs to both corners;
once the corner is reached, the anterior wall anastomoses is continued using
Connell stitches. The anterior serosal layer is not necessary to approximate. A
drain may be left in place. (Figure 2).
Figure 2. Anastomoses between the Gallbladder and a jejunal loop.
Figure 3. Laparoscopic port placement.
Bilioenteric Anastomoses
11
Cholecystojejunostomy (Laparoscopic)
Port Placement
The patient is placed in a supine position and the surgeon is placed in the
right side or standing between the legs of the patient. Four ports are necessary.
The first port is placed periumbilically (10-12 mm), a second (5 mm)
subxiphoid trocar is placed, a third port (10-12 mm) placed in the right
subcostal area in the nipple line and the fourth port (5 mm) is placed in the left
upper quadrant. (Figure 3).
Surgical Aspects
A 30 degree-angle scope is recommended. Once the ports are placed, a
general inspection of the abdominal cavity is performed and the organs to
anastomose are evaluated. The jejunal loop to be used is verified that it reaches
tension free and easily the sub-hepatic space. A cholecystostomy and
jejunostomy is performed using cautery or ultrasonic scalpel. Two stay sutures
can be placed to aid during the anastomoses. Side-to-side anastomosis is
performed using an endoscopic stapler (45 mm length and 2.5 mm thickness).
(Figure 4) The common enterotomy can be closed with interrupted absorbable
suture (3-0) or using a second cartridge of stapler. A close drain is placed.
Figure 4. Laparoscopic cholecystojejunostomy using and endoscopic stapler.
Miguel Ángel Mercado and Julio Alfaro Varela
12
Choledochoduodenostomy (Side-to-Side)
Incisions
A right subcostal incision with or without a vertical extension is an
excellent option (Hockey stick). A bilateral subcostal incision (Chevron) can
also be used or a midline incision. (Figure 5).
Figure 5. Types of incisions.
Surgical Aspects
The first step is to mobilize the colon inferiorly to allow adequate
exposure of the gallbladder, duodenum and hepatoduodenal ligament. (Figure
6) If the patient has previous surgeries, careful dissection and adhesiolysis has
to be performed. A Kocher maneuver is performed to allow adequate
mobilization of the duodenum to the site of the planned anastomosis. Close
attention must be paid to a tension free mobilization of the duodenum, being a
critical step to achieve a tension free anastomosis. (Figure 7) Cholecystectomy
is then performed in the classical manner. The hepatoduodenal ligament is
incised and a dilated common bile duct is exposed. Stay sutures (3-0) are
placed laterally to help with exposition and traction. Extensive dissection of
the bile duct has to be avoided. A choledochotomy is performed of at least 2.5
cm, close to the proximal superior border of the duodenum. A perpendicular
longitudinal duodenotomy is performed that has to be smaller than the
Bilioenteric Anastomoses
13
choledochotomy. (Figure 8) The posterior wall anastomoses are performed
using interrupted absorbable sutures (3-0 or 4-0) (Figure 9). The first suture is
placed in the 6 o´clock position and more sutures are placed to the 3 o´clock
and 9 o´clock position. The sutures must include all the wall of the common
bile duct and duodenum. The sutures are tied and the stay sutures are released.
All sutures are cut but the ones placed in the 3 o´clock and 9 o´clock position.
The anterior wall anastomosis is performed with interrupted absorbable
sutures (3-0 or 4-0) making sure the knot is left outside. Too many sutures are
not recommended. A close drain is placed.
Figure 6. Adequate exposition of the gallbladder, duodenum and hepatoduodenal
ligament is achieved after inferior mobilization of the colon.
Figure 7. A generous Kocher maneuver is performed to allow tension-free
anastomoses.
Miguel Ángel Mercado and Julio Alfaro Varela
14
Figure 8. The common bile duct is exposed and stay sutures are placed to help with
traction, a choledochotomy of at least 2.5 cm is performed close to the superior border
of the duodenum that will be anastomosed and the enterotomy is performed
perpendicular to the choledochotomy (solid line).
Figure 9. (a) Posterior wall anastomoses using interrupted sutures, stay sutures are
placed to help with traction. (b) Final appearance of the Choledochoduodenostomy.
Bilioenteric Anastomoses
15
Choledochojejunostomy (Side-to-side)
Incisions
A right subcostal incision with or without a vertical extension is an
excellent option (Hockey stick). A bilateral subcostal incision (Chevron) can
also be used or a midline incision. Chevron incision provides the best
exposure. (Figure 10).
Figure 10. Types of incisions.
Surgical Aspects
The colon must be mobilized inferiorly to allow adequate exposure of the
hepatoduodenal ligament. In redo operations adhesiolysis must be carefully
done. Cholecystectomy is performed in the traditional manner. Once the cystic
duct has been ligated it can be used as a reference landmark to be followed to
its junction with the common bile duct; the hepatic artery can also be used as a
reference landmark. A fine-needle syringe can be of aid in the identification of
the biliary tract or intraoperative ultrasound can also be used. As the
hepatoduodenal ligament has been opened and the common bile duct identify,
care must be taken to avoid excessive dissection of the biliary tract to avoid
injury to axial vascular structures. Sutures (3-0 or 4-0) that serve as traction
are placed laterally and above the area of stricture. A Roux-en-Y jejunal limb
is prepared for the anastomosis. The common bile duct is opened (at least 2
Miguel Ángel Mercado and Julio Alfaro Varela
16
cm) and is cleared of stones and sludge using randall forceps and biliary
fogartys. A smaller enterotomy is performed in the antimesenteric border of
the jejunal limb at 5 cm from the close end using cautery or ultrasonic scalpel.
The anastomosis is started with sutures on both corners, and interrupted
absorbable sutures (4-0) are placed with 3mm distance and include all the wall
of the common bile duct and jejunum. (Figure 11) The anterior wall
anastomosis is performed in the same manner. A close drain is placed. (Figure
12).
Figure 11. Choledochojejunostomy with a Roux-en-Y jejunal loop.
Figure 12. Final appearance of a choledochojejunostomy with Roux-en-Y retrocolic
jejunal limb.