Techniques of biliary reconstruction following bile duct resection (with video)

In most pancreatoduodenectomy cases, the bile duct is divided at the middle or superior part of the extrahepatic bile duct. In encircling the bile duct, it is important not to injure the right hepatic artery running just beneath the duct. Before dividing the bile duct, its duodenal side is simply ligated or closed with continuous suture, meanwhile the hepatic side should be occluded with a Bulldog-type vessel clamp. Electric cautery is used to divide the duct while coagulating the bleeding from the ductal wall. When intraoperative frozen section diagnosis is necessitated, division of the duct should be performed utilizing a surgical blade or scissors so as to preserve the surgical margin from heat damage caused by electric cautery. The clamp may be released just before starting the bilioenteric anastomosis to prevent contaminating the operative field with bile juice.

During the resection of the hilar or intrahepatic ducts, the orifice of the bile duct is revealed by dividing the fibrous connective tissue after removing the portal and arterial tributaries from the Glissonean pedicle [13] (Fig. 1). To avoid missing the ducts, a stay suture with atraumatic needle should be placed in the stump of each duct immediately at the time of detection. The suture has to be positioned in the estimated anterior wall of the anastomosis because it is used for preserving the intraluminal space by lifting it up in suturing of the anterior wall. After coagulating the bleeding from the bile duct wall, careful inspection is again necessary to avoid overlooking tiny branches of the bile ducts such as those arising from the caudate lobe, segment 4, or segment 5, which joins the hilar bile duct (Fig. 1); failure to do this can result in intractable postoperative bile leakage. With the appearance of smaller branches into which 5-French stent tubes cannot be inserted, anastomosis should be abandoned and the orifice closed with sufficient sutures. In patients with poor hepatic reserves, even small branches ought to be reconstructed by utilizing smaller tubes such as a part of disposable intravenous catheters.

Two neighboring duct orifices can be joined by two interrupted stitches to prepare them for anastomosis as a common channel [14, 15]. It might be better to use stay sutures during anastomosis (Fig. 2). In another reconstruction technique for plural neighboring ducts, the Glissonean sheath, including plural orifices, could be treated as a single duct by regarding the septa as a thick wall of the duct. When more than one duct orifice appears separately, plural orifices in the jejunum should be created according to the distance between the ducts. In the synchronous reconstruction of multiple individual anastomoses, entire rows of bile duct posterior walls should be accompanied first, followed by the anterior rows, because attempts to complete one anastomosis and then another may be difficult or sometimes impossible.

Sufficient jejunal limb length can usually be achieved by transecting the jejunum approximately 20 cm distal from the Treitz ligament via dissection of the 2nd or 3rd jejunal vessels. The limb is brought up in a retrocolic fashion to perform side-to-side anastomosis by means of a sufficiently large orifice made in the bottom of the mesocolon following the mobilization of the 2nd and 3rd portions of the duodenum. Alternatively, a retrogastric route can be used in patients who are morbid obese [16].

An anastomotic orifice in the jejunal limb should be created in a site that avoids tension at the anastomotic site by taking the length into concern that the stump of the jejunal limb would be attached to the peritoneum, because the transanastomotic tubes used for external biliary drainage should be brought out through the jejunal limb. As the jejunal incision becomes enlarged during the anastomosis, it should initially be smaller than the width of the bile duct.

The transanastomotic tubes we have used are 5-French polyvinyl chloride tubes (pancreatic duct drainage tube; Sumitomo Bakelite Co., Tokyo, Japan) that have a bulge 3 cm from the tip, multiple side holes, and a radiopaque line. The same number of tubes as bile ducts to be reconstructed are inserted through the jejunal incision and pulled out from the jejunal stump using blunt needles attached to the ends of the tubes (Fig. 3). The tip of each tube should be seized with mosquito forceps to prevent it from slipping out.

Single-layer interrupted sutures with 4-0 or 5-0 absorbable monofilament material are used for the anastomosis. Expert operators can use a limited number of continuous sutures in anastomosis of the extrahepatic duct. In the reconstruction of the intrahepatic duct, the wall of the bile duct appears as connective tissue after removing the portal vein and the hepatic artery from the Glissonean pedicle [13]. Thus, it is important to mobilize these vessels far enough away from the Glissonean pedicle to avert injuries caused by the suture needle during the anastomosis.

Firstly, two absorbable sutures 75 cm in length are placed in both corners of the jejunum and bile duct, in the case of the jejunum using a needle passing from the outside inwards and with the bile duct passing from the inside outwards to be tied on the outside of the anastomosis. The approximate center of each stitch is grasped by a rubber-shod clamp (small rubber-tipped forceps) so as to maintain distance between the jejunum and the bile duct by suspending them together, with the forceps clipping the bilateral ends of the stitch (ropeway method) (Fig. 4). Next, stitches using absorbable suture material 45 cm in length are placed so as to complete the posterior row approximating the jejunum and bile duct. The needles are passed through the jejunum at an interval of 1–2.5 mm from the inside outwards and through the bile duct from the outside inwards to be tied within the lumen. In order to maintain a favorable view during the anastomoses of multiple ducts, the stitches are serially introduced starting from the most dorsal side toward the ventral side. For the purpose of subsequent identification and prevention of suture tangling, both ends of the stitches should be grasped by small forceps and hung them in order with a large forceps. During suturing, stitches placed previously should be tented and moved aside by hooking with a right-angle forceps to prevent each stitch from tangling. When creating a large anastomosis, a stay suture placed in the center of the orifice can help surgeons to plan the suture interval. One of the sutures used for fixation of a transanastomotic stent might be clipped with a different type of forceps for easy recognition. Using a rapid-absorbing suture material for fixing the stent may enable it to be withdrawn without difficulty on the 14th postoperative day. After suturing the entire posterior row of the anastomosis, the clips for the ropeway method are released to “railroad” the jejunal limb down to the bile ducts’ orifices. The sutures except those at each corner are tied serially on the inside of the lumen. Surgeons should pay attention not to tear the bile duct by using improper ligation technique. Tied sutures of the posterior row are then cut, except the ones involved in stent fixation.

The stent tubes are inserted into bile ducts passing above the strings of the stent fixation suture, which form an opening in the shape of a letter “V” (Fig. 5). The fixation is usually performed on the proximal side of the bulge of the tube to prevent the tube from slipping out. In cases where the tube cannot be inserted deeply due to the small diameter of the duct, the fixation of the tube might alternatively be performed on the distal side of the tube’s bluge.

The anterior row of sutures is placed to complete the approximation of the jejunum and bile duct, using absorbable suture material of 45 cm in length. As with the posterior row, suturing should start at the most dorsal side and progress ventrally. The needles are passed through the jejunum from the outside inwards, and through the bile duct from the inside outwards to be tied on the outside. After the suturing of the entire anterior row of the anastomosis is complete, all sutures (including those at both corners) are tied serially on the outside of the anastomosis. The mucosal layer of the jejunum should be buried intraluminally during the tying. In cases requiring reconstruction of tiny branches where the intraluminal mucosal layer cannot be recognized, needles should be inserted along with the stent tube in order to securely stitch the mucosa of the duct.

The jejunal wall where the stent tubes have been pulled out is buried with interrupted sutures of seromuscular layer of the jejunum. After that, the tubes are fixed to the jejunal serosal layer with absorbable suture. Use of rapid-absorbing material is preferable in order to permit removal of the tube within a few weeks. The stump of the proximal jejunum is anastomosed with the side wall of the Roux-en-Y limb in end-to-side or side-to-side fashion.

In reconstructing the intrahepatic ducts, the portal side of the duct wall should be treated as the posterior wall of the anastomosis and sutured first, since this side is relatively thick and tough compared with the opposite side because of the existence of rich fibrous tissue. Of course, it is rather important to practice precise ligation technique, placing one of the fingers pulling the suture string beyond the tying point when making knots. If a wall is torn while tying the sutures, indwelling a perianastomotic sump tube with a continuous drainage system could be the best treatment instead of adding sutures over the torn duct. If a transanastomotic tube is adequately placed and the duct orifice is covered with the jejunum, the bile leakage could disappear within a few postoperative days as a result of the preemptive perianastomotic continuous drainage.

Especially in patients who undergo reconstruction of the relatively small intrahepatic branches, an external biliary drainage tube may not work at all or may stop aspirating suddenly during the early postoperative days. An obstruction of the stent tube may occur in these cases; however, no special treatment is necessary because bile juice can flow into the jejunum through the space between the luminal surface and the stent tube. Cholangiography via the stent tube should be strictly limited except in cases of severe and persistent bile leakage, because the procedure frequently causes severe cholangitis during the acute phase after the hepatectomy.