coledocoyeyunostomia anastomosis termino terminal

Los TERRYbles BooK TeaM


CHOLEDOCHOJEJUNOSTOMY (MUCOSAL GRAFT, RODNEY SMITH)

DETAILS OF PROCEDURE

The surgeon is occasionally faced with the difficult problem of finding the strictured area or

blind end of the hepatic duct. The adhesions between the duodenum and hilus of the liver are

divided carefully by sharp and blunt dissection (Figure 1). Great care must be exercised to

avoid unnecessary bleeding and possible injury to the underlying structures. Usually, it is

easier to start the dissection quite far laterally and to free up the superior surface of the right

lobe of the liver from the adherent duodenum, hepatic flexure of the colon, and omentum.

Sharp dissection is used along the liver margins to avoid tearing the liver capsule, which


results in a troublesome ooze. After the edge of the adhesion has been incised, blunt

dissection will be more effective and safer in freeing up the undersurface of the liver. The

exposure should be directed toward identifying and exposing the foramen of Winslow. The

stomach may or may not have to be dissected away from the liver. Usually, the duodenum is

drawn up into the old gallbladder bed and fixed by dense adhesions. The second portion of

the duodenum is mobilized medially (Kocher maneuver), following division of the peritoneum

along its lateral margin (Figure 2). As the duodenum is reflected downward and the

undersurface of the liver is retracted upward, the upper portion of the dilated duct may be

verified by aspiration of bile through a fine hypodermic needle (Figure 3), and a

cholangiogram may be performed. The needle may be left in place, and an incision is made

alongside the needle until a free flow of bile is obtained. A blunt-nosed, curved clamp is

inserted upward into the dilated duct and the opening gradually enlarged by dilatation, which

may include an additional incision to enlarge the opening. No effort is made to free up the

entire circumference of the ductal system, since the mucosal graft will eventually be

intussuscepted well up into the duct without a direct end-to-end anastomosis (Figure 6).

Following the opening of the dilated common hepatic duct, a long, curved clamp is inserted,

usually toward the left side, and extended up through the liver substance. A rubber or Silastic

tube (14 or 16 French) is pulled down through the liver and partially out through the duct

opening (Figure 4). Additional holes that will be above and below the anastomosis are made

in this tube. Following this, a Roux-en-Y arm of jejunum is prepared in the usual way. The end

of the mobilized jejunal arm is closed with two layers of interrupted silk. On the antimesenteric

border of the jejunum a 5-cm segment of the seromuscular coat is excised approximately 5

cm from the closed end (Figure 4). Care should be taken to avoid making any additional

openings in the mucosa except in the very apex of the protruding mucosal pocket. The tube

that was pulled down through the liver is now directed through the small opening made in the

apex of the mucosal pocket and directed down into the arm of jejunum for 10 cm or more. A

purse-string suture of absorbable suture is placed in the mucosa about the tube and tied.

After the tube has been passed the desired distance down the Roux-en-Y limb, a No. 2

absorbable suture is passed completely through the jejunal walls and around the tube to fix it

in position when tied just distal to the mucosal outpocketing. A centimeter or two distally a

similar absorbable suture is taken to ensure further fixation (Figure 6, A and B). These are the

only sutures utilized to fix the tube to the wall of the jejunum. These sutures ensure fixation of

the jejunal mucosa to the tube as it is withdrawn. Several holes are cut around the tube just

above the mucosal graft to ensure drainage of the right as well as the left hepatic duct.

Traction then is placed on the end of the tube coming out of the dome of the liver in order to

pull the mucosal graft carefully and firmly up into place inside the common hepatic duct. This

provides an intussusception of the jejunal mucosa up into the dilated common hepatic duct

and ensures direct mucosa-to-mucosa approximation (Figure 6). In very high strictures it may

be necessary to use a tube into the left as well as the right hepatic radical. Special tubes have

been devised for very high strictures that separate the right from the left hepatic ducts. The


Roux-en-Y loop is securely anchored in place beneath the liver by several absorbable sutures

placed through the seromuscular coat and the scar tissue around the opening into the duct

system (Figure 5).

CLOSURE

The tube is brought out through a separate stab wound to one side or the other of the incision

and anchored securely in place with nonabsorbable suture material. The wound is closed in

layers after suction drainage is instituted to the undersurface of the liver by a plastic tube with

many perforations.

POSTOPERATIVE CARE

The tube going to the anastomosis is placed on low-grade constant suction to divert bile until

the newly made junction is healed. The appropriate antibiotic therapy should be adjusted

following culture and sensitivity studies of the bile. The tube may be irrigated with saline

intermittently to wash out all debris or small calculi. In addition, the tube provides a means of

taking postoperative transhepatic cholangiograms from time to time to evaluate the security of

the anastomosis and the evidence of regression in the size of the formerly obstructed ducts.

Ordinarily, the tube is left in place for a minimum of four months. A complete evaluation with

liver function studies and several cultures of the bile should be made, as well as a

cholangiogram, before it is advisable to remove the tube.

END-TO-END ANASTOMOSIS

In rare instances the common duct may be divided accidentally and the injury discovered at

once. This is likely to occur just below the junction of the hepatic and cystic ducts as a result

of technical errors. The surgeon should always inspect the common and hepatic ducts at the

completion of cholecystectomy to make certain that they are not angulated or otherwise

injured. If there is any question, sufficient time should be spent to make certain that the

extrahepatic biliary system has not been damaged. If the common duct has been divided

completely, a direct end-to-end anastomosis may be performed.

The peritoneum on the lateral wall of the duodenum should be divided, and the duodenum

should be mobilized to relieve any possible tension on the suture line. Clamps are not applied

to the severed ends of the ducts. Irregular or frayed edges are excised, but clear zones are

not created as the common duct has a very tenuous blood supply. That is to say, the common

duct should not be cleaned either proximally or distally. Both ends of the duct are held in

position with guide sutures of fine 0000 nonabsorbable silk (Figure 7). A posterior layer of

interrupted sutures is placed without entering the lumen to approximate the posterior duct

walls (Figure 8). Upon completion of the posterior layer all of the sutures are divided except

one at either angle to serve for purposes of traction (Figure 9). The posterior layers of

mucous membrane are closed with very fine interrupted absorbable sutures. Following this

the common duct is exposed for a short distance, preferably downward, to permit the opening

of the duct, as in choledochostomy, and the introduction of a T-tube catheter (Figure 10). One


arm of the tube is passed up beyond the suture line to ensure an adequate lumen for the duct

when the anterior layer of sutures is placed, and the other is directed downward. If the duct

has been divided quite low, the opening may be made above the suture line with one arm of

the tube directed downward. The mucous membrane of the common duct is closed over the

T-tube with interrupted 0000 absorbable sutures with the knots on the inside (Figure 11). The

second layer of sutures may be placed close to the original layer to reinforce the line of

anastomosis (Figure 12).

All the sutures taken in the duct must be accurately placed with small needles and fine 0000

absorbable sutures and must include only a very small bite of tissue to avoid stenosis. After

the anastomosis has been completed, saline is injected into the catheter to make certain that

there is no leakage about the suture line, and a cholangiogram is made. A final inspection

verifies the absence of undue tension on the suture line. A closed-system suction catheter

made of Silastic is inserted past the foramen of Winslow into Morison's pouch.

CLOSURE

The Silastic drain and common-duct catheter are brought out through a stab wound lateral to

the incision. The wound is closed in the routine manner. The catheter is anchored to the skin

with a silk suture and adhesive tape. Sterile dressings are applied.

POSTOPERATIVE CARE See Choledochostomy, Transduodenal Approach.

coledocoyeyunostomia anastomosis termino terminal

Documents