168 Heptobiliary Surgery 13 The left duct and left branch of the portal vein are joined by the left branch of the hepatic artery, enter the umbilical fissure of the liver within which division of vessels to and confluence of ducts from the left lobe (Segments II and III) and the quadrate lobe (Segment IV) occur. The left hepatic duct receives major tributaries from each of these segments which converge in the umbilical fissure dorsocranial to the left portal vein. Hepatic ductal tributaries from the quadrate lobe (Segment IV) and hepatic arterial and portal venous branches supplying it re-curve to Segments IVA and IVB (Fig. 13.6). The ligamentum teres, in the lower edge of the falciform ligament, traverses the umbilical fissure of the liver which is usually, but not always, bridged in its lower- most part by a tongue of liver tissue joining the left lobe to the base of Segment IV. The ligament joins the umbilical portion of the left portal vein as it curves anteriorly and caudally, giving off branches to Segments II and III of the left lobe and to Segment IV (Fig. 13.6). The most common vascular anomaly is an accessory or replaced right hepatic artery originating from the superior mesenteric artery. This anomaly is present in about 20-25% of patients. The right hepatic artery runs posterolateral to the right of the common bile duct in close proximity to the cystic duct. The artery is prone to injury during cholecystectomy particularly if injury to the common bile duct occurs. Fig. 13.4. Relation of right and left hepatic ducts. Reprinted with permission from: Surgery of the Liver and Biliary Tract (3rd Edition), Blumgart LH, Fong Y and WH Jarnigan (Eds.) W.B. Saunders, London, UK (2000). 169 Surgical Techniques for Completion of a Bilioenteric Bypass 13 Its presence has to be ascertained prior to any isolation of the common bile duct in order to avoid injury. The techniques to be described rely upon a firm understanding of those ana- tomical features. Anastomoses are usually carried out either to the common, major right or left hepatic duct, or to the Segment III duct of the left lobe. General Considerations It is generally not necessary to proceed with biliary drainage prior to proceeding with a bilioenteric anastomosis in cases of obstructive jaundice. In fact, it is often easier to perform an anastomosis on a bile duct that is dilated secondary to obstruc- tion. However, preoperative biliary drainage is advised in patients with sepsis from cholangitis in order to stabilize the patient prior to surgery. It is of utmost importance to obtain as much information as possible on both the level and etiology of biliary obstruction prior to surgery. With the advent of high quality magnetic resonance cholangiopancreatography (MRCP), there is limited need for preoperative percutaneous or endoscopic cholangiography to determine the level Fig. 13.5. Extrahepatic course of the left hepatic duct within Glisson’s capsule. Reprinted with permission from: Surgery of the Liver and Biliary Tract (3rd Edition), Blumgart LH, Fong Y and WH Jarnigan (Eds.) W.B. Saunders, London, UK (2000). 170 Heptobiliary Surgery 13 of biliary obstruction. This holds true for both benign and malignant biliary stric- tures. MRCP has the advantage of not only providing information on the bile ducts, but also on the surrounding vascular structures as well as the liver parenchyma (Fig. 13.7). Immediate preoperative preparation should include the following: 1. Preoperative bowel preparation in cases where difficult adhesions to the colon are anticipated. 2. Preoperative broad-spectrum antibiotics, particularly if the biliary tree has been instrumented previously. 3. Central venous and arterial access is not always necessary for simple cases, but mandatory in cases with portal hypertension or cases including a liver resection. Fig. 13.6. Branching of portal pedicles within the umbilical fissure. A, left portal vein; B, left hepatic duct; C, Segment III sytem, note the duct (black) lies adjacent to the portal venous branch; D, ligamentum teres. Reprinted with permission from: Surgery of the Liver and Biliary Tract (3rd Edition), Blumgart LH, Fong Y and WH Jarnigan (Eds.) W.B. Saunders, London, UK (2000). 171 Surgical Techniques for Completion of a Bilioenteric Bypass 13 Fig. 13.7. An MRCP image demonstrating a cholangiocarcinoma. A large tumor is seen at the confluence of the right and left hepatic ducts. The gallbladder is distended which suggests origin or spread to the mid-bile duct causing cystic duct occulusion. Incisions Adequate exposure allowing full visualization is necessary for good biliary-enteric anastomosis. A midline incision allows access to the mid-common bile duct and can be adequate for a common duct exploration, choledochoduodenostomy, or a low hepaticojejunostomy. While being less morbid than a bilateral subcostal incision, it does not allow appropriate access to the hilus and should not be used if a hilar dissection is anticipated. If in doubt, a right subcostal incision is a better choice as it can be extended upwards to the xyphoid or across the midline as a bilateral subcostal incision, which allows excellent exposure of the extrahepatic bile duct and liver. If a bilateral subcos- tal incision is employed, the use of a broad-bladed retractor fixed to an overhead support elevating the costal margin is valuable. In cases of right lobar atrophy with posterior rotation of the hilar structures, it might be necessary to extend a bilateral subcostal incision into the right chest to provide safe access to the hilus. 172 Heptobiliary Surgery 13 Abdominal Exploration Upon opening the abdomen, it is important to fully expose the liver and the supracolic compartment of the abdomen. An important early step is division of the ligamentum teres and freeing of the falciform ligament from the abdominal wall back to the diaphragm. If previous surgery has been carried out, adhesions are care- fully taken down with great care to avoid bowel injury, particularly to the colon. Dissection of adhesions in the subhepatic area is best commenced from the right, mobilizing the colon from its adhesions to the undersurface of the liver, and work- ing medially so as to expose the area of the hilus. The duodenum will frequently be found adherent to the base of the liver; the colon may be densely adherent to the scar of the gallbladder fossa. At this point, one proceeds with the planned operation, resection in the case of a malignant stricture, or bypass in the case of benign or unresectable malignant strictures There are three critically important fundamentals in biliary-enteric anastomoses: 1. Identification of healthy, tumor-free bile duct mucosa proximal to the site of obstruction. 2. The preparation of a segment of the gastrointestinal tract, usually a Roux- en-Y loop of jejunum. 3. Direct mucosa-to-mucosa anastomosis between these two. In selected cases, the Roux-en-Y loop may be developed in such a way as to make its blind end subcutaneous (Fig. 13.8). If this technique is selected, the Roux loop must be made long enough to allow the blind end of the jejunum to reach the abdominal wall without tension. This technique will allow percutaneous access to the loop which may be necessary for adjuvant biliary tree intervention. When this is done, a silastic tube is left across the anastomosis and brought out through the loop in order to provide initial access. It should be emphasized, however, that in the usual circumstance, where an anastomosis is obtained between the mucosa of the bile duct and the jejunum, there is usually no need for transanastomotic tubes and no evidence that intubation assists long-term patency. The authors now advocate a simple sutured anastomosis in the average case. Indeed, transanastomotic stents carry their own complications and these are thus avoided. Basic Anastomotic Technique It is valuable to have an established routine for biliary-enteric anastomosis. Al- though some anastomoses are low and easily performed, a regular technique that facilitates the completion of the anastomosis, even in cases of high difficult stric- tures, should be developed. In brief, after the bile duct has been encircled and dilated, a Roux-en-Y loop of jejunum 70 cm in length is prepared and brought up (preferably in a retrocolic fashion) for completion of an end-to-side anastomosis. The end-to-side anastomosis is then performed using the technique described by Blumgart and Kelley (Figs. 13.9-13.13). The anterior layer of sutures is placed first and prior to any attempt to place the posterior row. If more than one ductal orifice is visible at the hilus, these are best approximated with a row of sutures so that they can be treated as a single duct for anastomotic purposes (Fig. 13.9). If this cannot be done, then the entire anterior row to all exposed ducts is inserted first so that the separated orifices can be treated 173 Surgical Techniques for Completion of a Bilioenteric Bypass 13 as if single. Attempts to complete one anastomosis and then another are difficult, and sometimes impossible. These sutures are serially introduced starting from the left and working to the right (Fig. 13.10). We recommend using a mono- or polyfilament absorbable suture of 4/0 size or smaller if necessary. This first step not only permits precise placement of the anterior row of sutures, which may be very difficult if the posterior layer is inserted first and tied, but also facilitates precise placement of the posterior layer (Fig. 13.11), which is likewise placed serially from left to right. The posterior layer of sutures is now tied (Fig. 13.12). The previously placed anterior row of sutures is now completed. Alternative Anastomotic Techniques In some cases, where the bile duct is large and easily exposed, a simpler tech- nique using a running suture can be employed. This technique is less time consum- ing than the above and can be used in most instances where the bile duct is anastomosed just proximal to the duodenum such as after a Whipple pancreaticoduodenectomy. Choledochojejunostomy or Hepaticojejunostomy This operation is usually performed in an end-to-side fashion; however, a side- to-side hepaticojejunostomy can be performed using techniques similar to those described for choledochoduodenostomy (see below). Fig. 13.8. Blind-end Roux-en-Y. Hepatocojejunostomy to the Segment III branch. The Roux-en-Y limb is brought out to the skin to provide subcutaneous access. The anastomosis is stented with a transjejunal tube which permits access for interventional diagnostic and therapeutic maneuver. 174 Heptobiliary Surgery 13 Fig. 13.9. Placement of the posterior row for hepaticojejunostomy. Reprinted with permission from: Surgery of the Liver and Biliary Tract (3rd Edition), Blumgart LH, Fong Y and WH Jarnigan (Eds.) W.B. Saunders, London, UK (2000). Technique The gallbladder, if present, is removed in a retrograde fashion. A tie is left in the cystic duct as an aid in manipulating the common bile duct. The common bile duct is dissected well above the obstruction, and care is taken to avoid an accessory or replaced right hepatic artery, if present. The duct is divided and the lower end of the common bile duct is closed with a running suture. The exposed common bile duct is now sutured into the jejunum using either technique described above. Approaches to the Left Duct Approaches to the left duct are useful in cases of high strictures where there is not enough bile duct proximally to perform an anastomosis. This can be the case secondary to a benign stricture after bile duct injury or due to a tumor. The left ductal system can be approached in two different ways: 1. Display the left hepatic ducts by opening the umbilical fissure, elevating the base of the quadrate lobe and lowering the left hepatic ductal system from the undersurface of the quadrate lobe (Hepp – Couinaud approach). 175 Surgical Techniques for Completion of a Bilioenteric Bypass 13 Fig. 13.10. Placement of the posterior row for hepaticojejunostomy. Reprinted with permission from: Surgery of the Liver and Biliary Tract (3rd Edition), Blumgart LH, Fong Y and WH Jarnigan (Eds.) W.B. Saunders, London, UK (2000). 2. Expose the left hepatic ducts by dissection at the base of the ligamentum teres (ligamentum teres or Segment III approach). Hepp–Couinaud Approach This technique allows performance of an anastomosis to the extrahepatic left bile duct in cases of high benign strictures, provided there is an intact communica- tion between the right and the left liver. The ligamentum teres is transected and a firm tie is placed so that it may be elevated and used as a retractor. The liver is elevated to display its undersurface. The bridge of tissue (if present), connecting the left lobe of the liver to the quadrate lobe, is divided with diathermy (Fig. 13.12). The hilar plate is now lowered. This consists of dissecting between Glisson’s capsule at the base of the quadrate lobe and the peritoneal reflection encasing the 176 Heptobiliary Surgery 13 Figs. 13.11A, 13.11B. Placement of anterior row for hepaticojejunostomy. Reprinted with permission from: Surgery of the Liver and Biliary Tract (3rd Edition), Blumgart LH, Fong Y and WH Jarnigan (Eds.) W.B. Saunders, London, UK (2000). Fig. 13.12. Cutting of the bridge of tissue connecting the left lobe of the liver to the quadrate lobe. Reprinted with permission from: Surgery of the Liver and Biliary Tract (3rd Edition), Blumgart LH, Fong Y and WH Jarnigan (Eds.) W.B. Saunders, London, UK (2000). 177 Surgical Techniques for Completion of a Bilioenteric Bypass 13 left portal triad (Figs. 13.13A, 13.13B). This maneuver allows exposure of the extra- hepatic left duct. Stay sutures are placed in the left hepatic duct which is then incised longitudi- nally. A Roux-en-Y loop of jejunum is brought up. Side-to-side anastomosis is then performed by the technique illustrated previously. Ligamentum Teres (Round Ligament) Segment III Approach While the vast majority of high benign strictures can be approached and dealt with as described above, it is occasionally difficult to expose the left hepatic duct beneath the quadrate lobe. This may be due to dense adhesions, bleeding, or a large Fig. 13.13A. Lowering of the hilar plate. A, The initial line of incision is shown. The hilar plate is lowered and the left hepatic duct is exposed. Reprinted with permis- sion from: Surgery of the Liver and Biliary Tract (3rd Edition), Blumgart LH, Fong Y and WH Jarnigan (Eds.) W.B. Saunders, London, UK (2000). [...]... Negative 3-year survival (%) Margin + Margin - Operative mortality (after liver resection) 8 27 60% 44% 56% 17. 5 mo* 22 mo* 7. 4% 30 23 57% 61% 39% 12% 50% 0% 4 18 21 85 43% 100% 33% 43% 67% 57% 21 mo * 11% 40 mo* 41% 5% 8.4% 18 125 76 % 27% 73 % 12.2% 40.1% 10.5% 23 109 7% 74 % 26% 9%** 19%** 6 .7% 14 28 100% 50% 50% 18% 40% 14% 8 16 50% 37% 63% N/A 43% 0% 19 138 90% 22% 78 % N/A 42 .7% 5.6% 14 76 86% 25% 75 %... end-to-side fashion between the exposed ducts and the side of the jejunal loop (close to the termination) using a single layer # 3-0 Vicryl interrupted suture employing the technique of Blumgart Hilar Cholangiocarcinoma: Surgical Approach and Outcome 1 97 Fig 14 .7 Resection of a hilar cholangiocarcinoma The left bile duct is identified (tumor-free) and transected Reprinted with permission from: Surgery. .. (Figs 13.1 5-1 3. 17) 13 Surgical Techniques for Completion of a Bilioenteric Bypass 181 Fig 13.15 Lines of incision Choledochoduodenostomy performed using an interrupted technique Reprinted with permission from: Surgery of the Liver and Biliary Tract (3rd Edition), Blumgart LH, Fong Y and WH Jarnigan (Eds.) W.B Saunders, London, UK (2000) 13 182 Heptobiliary Surgery 13 Fig 13.16, top Fig 13. 17, bottom... specimens and 9-3 6% of liver explants, and choledochal cysts or Caroli’s disease which demonstrate a 2. 5-2 8% incidence of malignant transformation Oriental cholangiohepatitis, a rare form of pyogenic cholangitis, also has a 5-1 2% lifetime incidence of cholangiocarcinoma Additional risk factors include biliary tract infection with parasites (e.g., Clonorchis sinensis and Hepatobiliary Surgery, edited... months and actuarial 3- and 5-year survival of 20 and 13% respectively Fong et al reported on 104 patients with distal bile duct cancer of which 45 patients were resected (43%) Thirty-nine patients underwent a pancreaticoduodenectomy, and six patients had a common bile duct excision only A negative histologic margin was obtained in 86% of cases Mean survival for the 14 188 Heptobiliary Surgery Fig 14.3B... into right and left hepatic ducts Middle third tumors ( 17% ) are located from the upper border of the duodenum and extending to the cystic duct junction Lower third or distal bile duct tumors (1 8-2 7% ) arise between the ampulla of Vater and the upper border of the duodenum Intrahepatic cholangiocarcinoma (IHC) are rare neoplasms accounting for 6-1 0% of all cholangiocarcinoma and are managed similarly... 9%** 19%** 6 .7% 14 28 100% 50% 50% 18% 40% 14% 8 16 50% 37% 63% N/A 43% 0% 19 138 90% 22% 78 % N/A 42 .7% 5.6% 14 76 86% 25% 75 % 8% 40% 4.6% 6 30 73 % 17% 83% 0%** 56%** 6% * Figures reflect median survival ** Figures reflect 5-year survival rates Heptobiliary Surgery Hadjis, 1990 Bismuth, 1992 Baer, 1992 Suigura 1994 Pichlmayr, 1996 Nakeeb, 1996 Madariaga, 1998 Figueras, 1998 Nagino, 1998 Miyasaki, 1998... with HCCA in which 125 patients underwent resection, and 25 patients underwent OLT Resectional therapy yielded equivalent or superior overall 5-year survival ( 27. 1% versus 17. 1%) at all stages of disease Klempnauer et al have subsequently reported on four (12.5%) 5-year survivors out of a total of 32 patients that underwent OLT for HCCA During this same time period 151 HCCA patients were resected with... frequently three, four, or even five ducts exposed Adjacent ducts are sutured together using # 4-0 Vicryl suture It is usually possible to create situations in which there are no more than three separate orifices to be anastomosed A suitable Roux-en-Y loop of jejunum is now prepared by dividing the jejunum 1 0-1 5 cm distal to the ligament of Treitz with a GIA stapler The Roux limb is usually brought up... Blumgart ©2003 Landes Bioscience 184 Heptobiliary Surgery Fig 14.1 Anatomic distribution of cholangiocarcinoma based on site-specific percentages 14 Opisthorchis viverrin), chronic typhoid carrier states, and exposure to various chemical carcinogens, including asbestos, digoxin, and nitrosamines Cholangiocarcinomas are generally well-differentiated slow-growing adenocarcinomas which may be mucin producing . and dilated, a Roux-en-Y loop of jejunum 70 cm in length is prepared and brought up (preferably in a retrocolic fashion) for completion of an end-to-side anastomosis. The end-to-side anastomosis is. the gastrointestinal tract, usually a Roux- en-Y loop of jejunum. 3. Direct mucosa-to-mucosa anastomosis between these two. In selected cases, the Roux-en-Y loop may be developed in such a way as. end-to-side fashion; however, a side- to-side hepaticojejunostomy can be performed using techniques similar to those described for choledochoduodenostomy (see below). Fig. 13.8. Blind-end Roux-en-Y.