Biliary Drainage Procedures
PREOPERATIVE PREPARATION
Preoperative preparation is essentially similar to that described for a cholecystectomy. Surgical biliary procedures are primarily performed for decompression in the presence of obstruction within the extrahepatic biliary system. A variety of methods are described, and their use will depend on the site of obstruction; the mode of presentation, namely whether it is chronic or acute; and the suspected underlying pathology.
Operative Procedure
POSITION
The patient is placed in the supine position on an operating table that allows the surgeon to perform operative cholangiography.
INCISION
The incisions most commonly used for exploration of the bile ducts are the subcostal (Kocher) incision and the upper midline incision. The choice between these two incisions depends on surgeon preference and other structures that may need to be exposed.
Cholecystostomy
In high-risk patients cholecystotomy may be performed percutaneously by an interventional radiologist. This procedure, however, is performed very rarely and only under special circumstances, either because of the poor general condition of the patient or as a result of associated severe cirrhosis that may make cholecystectomy hazardous. However, if there is evidence of either perforation or gangrenous cholecystitis, cholecystectomy is preferable.
Once the peritoneal cavity is entered, a careful exploration is performed. Moist laparotomy pads are placed in Morison’s pouch to avoid any spillage of bile. A purse-string suture using 2-0 silk is placed at the fundus of the gallbladder. A second purse-string suture using 2-0 silk is placed 1 cm away. A trocar is placed through the fundus of the gallbladder to empty its contents. Once the gallbladder is decompressed, often gallstones can be palpated at the neck; these can easily be milked out or removed using Desjardins forceps. The trocar is removed, and through the same stab incision a 20 Fr Foley or a Malecot catheter is placed into the gallbladder. If a Foley catheter is used, the balloon is inflated with 5 to 10 mL of distilled water. The purse-string suture is tied down securely. To seal the fundus of the gallbladder and to prevent bile leak, the second purse-string suture is snugly tied down. The long end of the Foley is brought out through a separate stab incision in the anterior abdominal wall and secured with 3-0 nonabsorbable monofilament sutures. A 10-mm Jackson-Pratt drain is left in the hepatorenal fossa to drain potential bile leaks.
Transduodenal Sphincteroplasty
Sphincteroplasty is a useful procedure where there is impaction of a gallstone in the ampulla of Vater or fibrous stricture of the sphincter of Oddi. Initially, the common bile duct is exposed just proximal to the first part of the duodenum. Next, a Kocher maneuver is performed. Two 4-0 silk stay sutures are placed on the anterior wall of the common bile duct, and a longitudinal incision is made as close to the duodenum as possible, in case a choledochoduodenostomy becomes necessary. Through the choledochotomy, a Bakes dilator is passed to the level of the ampulla. The site where the tip of the Bakes dilator is palpated can be used to center the longitudinal incision on the anterior duodenal wall. By placing stay sutures at the edges, the operator can retract the duodenal wall outward to improve exposure. The direction in which the Bakes dilator lies provides a clue to the course of the distal common bile duct. Keeping this in mind, two stay sutures using 4-0 silk are placed at the level of the ampulla, and an oblique incision at approximately the 11 o’clock position is made. If there is an impacted stone, this should be removed from below. A rush of bile may be seen emerging through the sphincterotomy. After this initial incision of the ampulla, graduated Bakes dilators can be readily passed from above through the sphincter and into the duodenum. Any fine biliary stones or debris can be flushed from above using saline irrigations through a red Robinson catheter. The sphincterotomy should be approximately 1.5 cm and can be extended with Pott scissors. Once the operator is satisfied with the length of the sphincterotomy, interrupted simple sutures using 4-0 absorbable sutures are placed at the two edges of the sphincterotomy. To avoid the possibility of bile leak, a figure-of-eight suture is placed at the apex of the sphincterotomy. The duodenotomy is closed in the usual fashion in two layers with an inner continuous Connell suture using 3-0 absorbable sutures and an outer seromuscular layer of interrupted 3-0 silk Lembert sutures. Finally, a 10-mm Jackson-Pratt drain is placed in the hepatorenal fossa.
Choledochoduodenostomy
For this procedure to be performed, the diameter of the common bile duct must be greater than 1.5 cm because the anastomosis between the common bile duct and the duodenum should be at least 2.5 cm in diameter to allow free drainage of bile. The peritoneal covering over the common bile duct is carefully cleared, using blunt dissection with a Kittner, avoiding any dissection on the lateral aspect because this can injure the delicate blood supply. A Kocher maneuver is required before performing a tension-free anastomosis. Two stay sutures using 4-0 silk are placed on the anterior surface of the common bile duct. A longitudinal incision, measuring approximately 1.5 to 2.0 cm, is made in the common bile duct as close to the duodenum as possible. Next, after placement of two stay sutures, a transverse incision is made in the first part of the duodenum adjacent to the common bowel duct. A one-layer anastomosis is sufficient and can be constructed with a single layer of interrupted 3-0 absorbable sutures. A 10-mm Jackson-Pratt drain is placed in the hepatorenal (Morison’s pouch) fossa.
Choledochojejunostomy/Hepaticojejunostomy
When an anastomosis between the bowel and the common hepatic or common bile duct is needed, the jejunum becomes the preferable conduit. The common bile duct is identified and its anterior surface dissected in preparation for the anastomosis. The ligament of Treitz is identified, and 15 cm distal to this point, the jejunum is transected using a GIA linear stapler. The peritoneum lining over the mesentery is incised with electrocautery, and at least two or three of the vascular arcades are divided and ligated to allow the distal segment of the jejunum to reach the bile duct. An opening is made in the nonvascular portion of the transverse mesocolon, and the distal jejunal limb is passed through this defect toward the common bile duct. The anastomosis can be side to end, end to side, or end to end. However, an end (common bile duct)-to-side (jejunum) anastomosis is preferred, and it requires transection of the common bile or common hepatic duct. A one-layer anastomosis is constructed by approximating mucosa to mucosa with simple interrupted 4-0 absorbable sutures. Just before the anterior layer of the anastomosis is completed, a T-tube is placed as a stent and the longer limb is brought out through the bile duct. If the anastomosis is constructed for a bile duct injury in the acute setting, the common bile duct is generally of normal caliber, and therefore the anastomosis needs to be protected with a T-tube. To avoid any tension on the anastomosis, the jejunum is secured to the adjacent liver capsule or the adjacent peritoneal lining of the lesser omentum. Finally, a hand-sewn end-to-side jejunojejunostomy is performed about 60 cm from the choledochojejunostomy with an inner continuous layer of 3-0 absorbable sutures and an outer layer of 3-0 silk Lembert sutures. A few interrupted sutures between the mesocolon and the jejunal limb are placed to close the defect in the mesocolon. A 10-mm Jackson-Pratt drain is placed in the right upper quadrant.