clavien_atlas_of_upper_gastrointestinal_and_hepato-pancreato-biliary_surgery2007-10-01_3540200045_springer

The left intrahepatic bile duct is identified at the right edge of Rex’s recess. Two stay sutures are placed ventrally and dorsally (A), the left hepatic duct is transected perpendicularly, and the right liver, caudate lobe and extrahepatic bile duct are removed (B). At the ventral edge of the resected margin of the left hepatic duct, the bile duct of segment 4 is opened followed by the segments 2 and 3 dorsally.

Local Postoperative Complications

■Short term:

–(Pleural effusion)

–Wound infection

–Bile leak from hepaticojejunostomy or raw surface of the liver

–Subphrenic or subhepatic abscess

–Intra-abdominal bleeding

–Liver failure

–Portal vein thrombosis

■Long term:

–Cholangitis

–Anastomotic stricture

–Chronic liver failure

Tricks of the Senior Surgeon

■Check the intraoperative external biliary drainage to prevent unexpected biliary congestion from which septic complications may develop.

■Suture the large short hepatic veins or caudate lobe veins in detaching the caudate lobe from the vena cava.

■Check the CVP in the monitor before liver transection. If the CVP is higher than 3cm H2O, do not start to transect the liver.

■The hepatic vein on the liver side should be closed by a running suture to prevent bleeding during the handling of the liver.

■Stay sutures should be placed before dividing the intrahepatic bile duct, otherwise the small segmental duct will slip away and be hidden by the liver parenchyma.

■The lymphatic vessels should be tied in a para-aortic lymph node dissection to prevent postoperative massive lymphorrhea.

Editor’s Comments

■Tissue diagnosis is not a prerequisite for surgical resection of suspected cholangiocarcinoma – clinical presentation and radiographic appearance is enough.

■ERCP and peroral cholangioscopy are avoided for high bile duct obstruction since these are unlikely to define the problems or palliate obstruction, and can lead to cholangitis.

■Percutaneous drainage is not always necessary prior to surgery. The patients who will benefit from preoperative drainage are those who (1) have cholangitis, (2) have renal dysfunction, (3) have possible vascular invasion on the side that will be the remnant liver after resection or (4) should undergo portal vein embolization.

■In mobilizing the candidate lobe for a patient who will be subjected to a left lobectomy and caudate resection, it is usually safest to mobilize the caudate from the right to the left. Only in the thinnest patients is it safe to perform the mobilization from the left.

■Some surgeons believe that caudate resection is an essential part of every resection for hilar cholangiocarcinoma, while others believe that resecting this portion of the liver is indicated only when the caudate lobe is directly involved by tumor.

Resection of the Mid Common Bile Duct

Chandrajit P. Raut, Jean-Nicolas Vauthey

Introduction

True mid bile duct tumors are very rare. Most patients with mid bile duct obstruction should be considered to have gallbladder cancer until proven otherwise. Mid bile duct resections are usually performed for the rare mid duct cholangiocarcinomas or for patients with early gallbladder cancer and tumor at the cystic duct margin.

Indications and Contraindications

Preoperative Investigation and Preparation for the Procedure

parasites, exposure to chemical carcinogens

Clinical evaluation: Jaundice (90–98% of patients), weight loss (51%), abdominal pain

exposure of the undersurface of the liver. If present, the bridge of liver parenchyma between segment 4 and the left lateral bisegment is divided with electrocautery; bleeding is easily controlled as this tissue rarely contains large vessels. This maneuver exposes the umbilical fissure for a later step.

The gallbladder, if present, is dissected free from its liver bed. The proximal CBD and the right and left hepatic ducts are dilated proximal to the stricture, unless stenting across the stricture has drained the obstruction. The distal CBD is isolated and divided early in the dissection above the superior edge of the pancreas and a frozen section analysis of the margin is obtained. The distal CBD stump is ligated in a figure-of-eight fashion with 4-0 PDS suture on an SH needle.

The biliary-enteric continuity is restored with a side-to-side retrocolic Roux-en-Y hepaticojejunostomy with a single layer of interrupted, absorbable sutures (5-0 PDS vs. an shRVI needle as preferred by the authors). This technique incorporates the extrahepatic portion of the left duct in the anastomosis, as first described by Hepp and Couinaud, thus creating a wide side-to-side hepaticojejunostomy. A 70-cm jejunal Roux-en-Y limb is prepared and brought through the transverse mesocolon to the right of the middle colic artery; the stapled end does not need to be oversewn. Both the left duct and the jejunum are incised longitudinally for a 2-cm-wide anastomosis. The anterior row of No.5-0 absorbable sutures is brought through the bile duct wall and the needles are left intact (A). A Gabbay-Fisher suture guide (Genzyme Co., Fall River, MA) facilitates the management of these free sutures by organizing them; each guide holds up to 16 sutures. Gentle retraction on these sutures superiorly allows exposure of the posterior edge of the ductal incision. Precise mucosa-to-mucosa anastomosis is established with interrupted No.5-0 absorbable sutures between the posterior edge of the ductal incision and the posterior edge of the jejunal incision. The posterior sutures are tied with the knots on the inside (B). The anterior stay sutures are then placed through the jejunum to complete the anterior row of sutures. These are tied such that the knots are exterior (C). Internal stenting is not required. A drain on bulb suction is left near the anastomosis and brought through the abdominal wall in the right upper quadrant.

Tricks of the Senior Surgeon

■Preoperative biliary drainage with a transtumoral catheter may be of technical assistance for the hilar dissection and biliary enteric anastomosis, but does not reduce perioperative morbidity or duration of hospitalization. Drainage is only indicated in patients with sepsis and cholangitis.

■If present, the bridge of liver parenchyma between segment 4 and the left lateral bisegment is divided by electrocautery.

■Duct margins should be submitted for intraoperative frozen section analysis.

■A Gabbay-Fisher suture guide facilitates the management of these free sutures by organizing them to minimize entanglement; each guide holds up to 16 sutures.

■Internal stenting is not required.

■Resection and reconstruction utilizing the Hepp-Couinaud approach, which employs a wide mucosa-to-mucosa anastomosis extended to the left hepatic duct, has the advantage over an end-to-side anastomosis of having a lower rate of stricturing.