clavien_atlas_of_upper_gastrointestinal_and_hepato-pancreato-biliary_surgery2007-10-01_3540200045_springer

■Primary CBD closure: is used when there is no doubt about the complete CBD vacuity, in the absence of severe cholangitis and when papillary obstruction is absent (permeable sphincter of Oddi, absence of edema due to transpapillary instrumental maneuvers, etc.).

■External biliary drainage: by using a transcystic drain (see TCBDE) or a T-tube. In case of T-tube placement, the tube is fenestrated and then inserted into the CBD through the choledochotomy. The CBD suture is started after having pushed the tube at the upper corner of the choledochotomy (A). Then the T-tube is exteriorized through the site of the fifth trocar.

■Internal biliary drainage using an endoprosthesis:

–Indication: When the number of CBDs is limited, the stone clearance is accurate and in the absence of pancreatitis or Oddi dysfunction.

–Technique: The endoprosthesis is pushed under fluoroscopic guidance on

a guidewire into the CBD and through the papilla into the duodenum. Adequate transpapillary positioning is assessed by transcystic cholangiography at the end of the procedure (B).

– The endoprosthesis is removed 3weeks later by a standard duodenoscopy.

STEP 7

Perform control cholangiography at the end of the procedure to detect biliary leak or transcystic drain or T-tube misplacement.

STEP 8

Routine peritoneal drainage is used.

Postoperative Tests

■Clinical assessment

■Check biliary drains

■Laboratory tests: liver function tests, pancreatic enzymes

■Control cholangiography at postoperative days 2–3 (before hospital discharge) if a TC or a T-tube drain is in place, to exclude a residual CBDS or a biliary leak

Postoperative Complications

Local Complications

■Residual CBDS

■Bile leak

■Hemorrhage

■Subhepatic abscess

■Late biliary stricture

Due to External Biliary Drain

■Patient discomfort

■Electrolyte abnormalities

■Postradiologic cholangitis

■Tube obstruction

■Accidental tube removal

■Wound infection

■Bile peritonitis at extraction

Tricks of the Senior Surgeon

■Look carefully at pictures of IOC to decide the optimal strategy for CBDE;

this will save operative time and decrease possible instrumental complications.

■Use soft, atraumatic instruments in the CBD and perform instrumental TCBDE under fluoroscopic guidance, to avoid CBD injury.

■When the suture of choledochotomy is completed, use a water-tightness test by blowing up the CBD with saline solution or methylene blue through a transcystic cholangiographic catheter or drain or through the T-tube.

■In case of failure of CBDE, postoperative endoscopic sphincterotomy can be planned. In these circumstances, placement of a transcystic biliary drain will optimize the success rate of the further endoscopic procedure.

Exploration of the Common Bile Duct:

The Open Approach

Introduction

The first choledochotomy through laparotomy was reported by Kehr in 1896 and was the surgical treatment of choice for many years. However, since the 1990s, the open approach has been increasingly abandoned in favor of the laparoscopic procedure for CBDE.

Indications and Contraindications

Contraindications, Preoperative Investigations, Postoperative Tests and Postoperative Complications

These are similar to those for LCBDE.

Procedure

Incision and Exposure

Right subcostal or upper middle-line incision. The hepatoduodenal ligament is more easily stretched than for LCBDE, by pulling up the quadrate lobe using a retractor and pulling down the pancreatic head by using the assisting surgeon’s hand.

Bile Duct Resection

Yuji Nimura

Introduction

Resection of tumors at the bifurcation of the left and right hepatic duct requires one of the most difficult operations. The surgical procedure requires not only a portal

lymphadenectomy and bile duct resection, but almost always a liver resection. The goals of this operation are: (1) resection of the primary tumor, (2) resection of the lymphatic drainage of the liver and (3) reestablishment of biliary continuity.

Indications and Contraindications

Absolute Contraindications ■ Biliary carcinoma with distant organ metastasis (liver, lung, bone, peritoneum)

■Uncontrollable severe cholangitis with or without sepsis

■Poor liver reserve with prolonged cholestasis

■Severe coagulopathy despite vitamin K administration

What we should not do

A metallic stent should not be used in resectable biliary carcinoma.

Preparation Prior to Surgery

■Antibiotics sensitive to bile culture

■Percutaneous transhepatic biliary drainage (endoscopic biliary drainage is not advisable)

■Portal vein embolization for major hepatectomy

■Internal biliary drainage or bile replacement through a nasogastric tube for patients with external biliary drainage

The Kocher maneuver is performed to mobilize the duodenum and allow dissection of the distal bile duct. The distal bile duct is dissected down to the head of the pancreas and divided above the pancreas. The resection margin must be examined by frozen section.

In some cases this procedure should be advanced more distally to detach the bile duct from the pancreatic tissue and resect the duct in the pancreas with a free margin.