Reconstruction of Bile Duct Injuries Steven M. Strasberg

Reconstruction of Bile Duct Injuries

Steven M. Strasberg

Introduction

Bile duct injuries have become more common since the introduction of laparoscopic surgery and are a major source of morbidity and litigation. Bile duct injuries may take many forms. Simpler injuries such as types A and D may be treated in the community setting when discovered intraoperatively or by endoscopic or percutaneous techniques when they present in the postoperative period. Some more complex injuries such as E1 and E2 types may also be treated by nonsurgical techniques when they present as stric- tures. This chapter deals with the more complex injuries that require hepaticojejunos- tomy for repair (types B and C injuries and most to type E injuries).

The figure illustrates the classification of injuries to the biliary tract. Type E injuries are subdivided according to the Bismuth classification. Types B and C injuries almost always involve aberrant right hepatic ducts. The notations >2 cm and <2 cm in types

and E2 injuries indicate the length of common hepatic duct remaining.

The injuries with an isolated right duct component and the subject of this paper are

types B,

and E5.

Timing of Repair

Factors favoring immediate repair are: (1) early referral, (2) lack of right upper quadrant bile collection, (3) simple injuries, (4) no vascular injury and (5) a stable patient. Factors favoring delayed repair are: (1) late (less than 1week after injury) referral, (2) complex injuries (types E4, E5), (3) thermal etiology and (4) concomitant ischemic injury.

Preoperative Investigation and Preparation for the Procedure

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Communication with previous surgeon

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Previous surgical report

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Laboratory tests: bilirubin, alkaline phosphatase, ALT, AST, albumin, coagulation parameters, white blood cell count

Principles of Repair

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Anastomosis should be tension free, with good blood supply, mucosa to mucosa and of adequate caliber.

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Hepaticojejunostomy should be used in preference to either choledochocholedoco- tomy or choledochoduodenostomy.

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An anterior longitudinal opening in the bile duct with a long side-to-side anasto- mosis is preferred.

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Dissection behind the ducts should be minimized in order to minimize devascu- larization of the duct.

Use of Postoperative Stents

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There is no evidence that they are helpful if a large caliber mucosa-to-mucosa anastomosis has been achieved.

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We use them when very small ducts have been anastomosed.

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Transhepatic tubes can be left through the anastomosis in order to perform postoperative cholangiography.

More Radical Solutions

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When ductal reconstruction to a part of the liver is impossible, then resection should be performed.

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Occasionally prior failure of reconstruction leads to secondary biliary cirrhosis,

end-stage liver failure, and a need for liver transplantation.

Procedure

Incision

The usual incision is a J-shaped right upper quadrant incision shown as a solid line.

The vertical length of the incision should be at least 6 cm. The incision can be extended

to the left (dotted line for increased exposure in large individuals). A midline incision

may be suitable for thin persons. A large ring retractor is placed after clearing adhesions

to the anterior abdominal wall.

STEP 1

Schematic of the principles of the Hepp-Couinaud approach. This approach is adequate for types E1–E3 lesions. The dissection is started at the liver edge and carried down the face of segments 3–5 until portal structures are encountered. The dissection is continued directly on segment 4 in the plane shown (A). The end point of the dissection is entry into liver tissue in this plane. The liver plate (Wallerian sheath) is divided and the left bile duct identified just below this level. The left duct is accessed because it has a long extrahepatic length as opposed to the right. The left duct may lie horizontally as shown here or more vertically, in which case the dissection is more difficult. This dissection is facilitated by division of the bridge of liver tissue between segments 3 and 4 (B) and by reopening the gallbladder fossa when it has sealed at its lips. Resection of the inferior portion of segment 4 may also be helpful (see below).

A

B

STEP 2

At this point a stent in the left duct can be palpated and the duct opened on its anterior surface. A 2-cm opening is adequate. Care should be taken not to extend the incision too far to the left, as the hepatic artery to segment 4 may be injured. Segment 4 is pulled up, the liver plate divided and the left hepatic duct identified. A Roux-en-Y loop has been prepared. The loop is laid up as shown. The double-headed arrows indicate the sites of openings that are made in the duct and the bowel.

STEP 3

The anastomosis is performed with synthetic absorbable interrupted sutures (5-0 sutures are preferred by the author). The anterior row in the bile duct is placed first, then the posterior row in both structures is placed and tied, and finally the anterior row is placed in the bowel and tied (see chapter on biliary-enteric anastomosis: pages).

A single suction drain is left. Stents are used only when the bile ducts are very small

2 mm or less; this is very uncommon.

Cases of Isolated Right Hepatic Duct

In types E4 and E5 and B and C injuries the Hepp-Couinaud approach alone will not suffice, as there is an isolated portion of the biliary tree on the right side. The key to dissection is based on the fact that the main right and left bile ducts lie in the same coronal plane, invested in fibrous Wallerian sheaths. Also of importance is that the gall- bladder plate, a layer of fibrous tissue on which the gallbladder normally rests, attaches to the anterior surface of the sheath of the main right portal pedicle. To find the bile duct within the sheath of the pedicle the cystic plate must be detached from the anterior surface of the sheath of the right portal pedicle.

STEP 1

The liver capsule is divided toward the right until the cystic plate is met where it

attaches to the sheath of the right portal pedicle. It is a stout ribbon of fibrous tissue

about 2mm in thickness and 5–8mm in breadth.

STEP 2

After dividing the cystic plate the liver lifts off the right portal pedicle. The division of the liver capsule is carried about 1cm beyond the cystic plate. Now the liver (segment 5) may be dissected off the portal pedicle, by lifting and coring the base of segment 5. This exposes the anterior surface of the sheath of the right portal pedicle. The position of the right duct(s) in the pedicle is evident from the position of the stent (not shown). To prepare the right bile duct for anastomosis it is opened on the anterior surface (inset).

Ideally, the duct(s) is opened 1cm. The entire anastomosis is then performed to the ante-

rior surface of the duct as described above for the left duct. When performing two (or

more) anastomoses the anterior row in the bile ducts should be placed first and then the

posterior row placed and tied, completing all anastomoses together by placement

of the anterior row sutures in the bowel and tying of all anterior row sutures.

Access to Intrahepatic Ducts Provided by Partial Hepatectomy

In some cases, especially those in which there have been repeated bouts of cholangitis and the liver has become swollen and fibrotic, a condition most frequently seen after failed hepaticojejunostomy, segment 4 may overhang the upper bile ducts. In these cases resection or coring of segment 4 is also a useful adjunct. Resection provides excellent access to the upper part of the porta hepatis without relying on forceful retraction on the liver and provides room for the bowel to rest when the hepaticojejunostomy is performed. This maneuver is not restricted only to operations in which a portion of the right biliary tree has been isolated. It is also useful for types E3 and some E2 injuries.

Bile ducts with stents may be seen at the bottom of the picture.

Close-up of bile ducts. Type E4 injury in which the right bile ducts have been exposed by dividing the gallbladder plate as described and segment 4 has been partially resected.

Preoperatively placed stents are emanating from the ducts, and the ducts have been incised on their anterior surfaces for 1.5cm. Sutures have been placed in the anterior row of the proposed anastomosis along with a few in the posterior row (A).

In figure

anastomosis because the ducts were close and the intervening scar small. Although the

center of the anastomosis may scar, the long lateral horns are mucosa to mucosa and

effectively a double-barreled anastomosis results.