Bile Duct Repair

• Anesthesiologist
• Operating surgeon
• Surgical technician
• First assistant
• Circulating nurse
• Interventional radiologist if preoperative PTC required
• Gastroenterologist if ERCP required
• Radiology technician for fluoroscopic assistance

For delayed repair of a biliary injury, the biliary tree will have been thoroughly investigated with various modalities of cholangiography. The patient should be adequately treated for sepsis, bile leak, or biliary obstruction with antibiotics, IR-guided drainage or PTC/ERCP with biliary stenting and drainage. For high common duct injuries, percutaneous stents placed in the proximal injured bile ducts are a valuable tool for identification intraoperatively.

Preoperative area

• Hair removal in the surgical field may be performed with the use of clippers
• A perioperative antibiotic will be administered 30 minutes prior to incision
• An epidural catheter may be considered for perioperative pain control and limiting the use of intravenous narcotics 

Operating room

• Patient position: supine.
• Anesthesia: General with endotracheal intubation
• The abdomen will be prepped and draped in the usual sterile fashion

• The following describes an open repair of bile duct injury.

• Incision and exposure: A variety of incisions may be placed to accomplish the bile duct repair. The most commonly performed is the right subcostal incision. It provides adequate exposure. A “hockey stick” incision is the midline extension of the subcostal incision. Alternately, an upper midline incision may be utilized. Dissection is carried through the abdominal wall, and the peritoneal cavity is entered. The self-retaining laparotomy retractor is then placed, and the surrounding adhesions are taken down. The adhesions are typically significant around the injured bile duct and must be lysed to completely mobilize and free up the quadrate lobe (segment IVb).

• Complete the cholecystectomy if not already done

• All visualized clips are removed, and the bile ducts are confirmed with the help of needle aspiration of bile. A cholangiogram is performed in the ducts proximal to the injury to visualize all segments of the liver and identify aberrant bile duct anatomy.

• A Kocher maneuver is performed (release the lateral attachments to the second portion of the duodenum which is then reflected medially to expose the posterior duodenum, pancreas, and retroperitoneum). This will facilitate exposure of the distal common bile duct stump which will be closed utilizing a continuous running permanent suture.

• Exposure of the left hepatic duct (LHD): The hilar plate (extension of Glisson’s capsule from the liver onto the hepatic ducts) is incised anteriorly to the LHD thus lowering and facilitating exposure of the duct.

• Exposure of the right hepatic duct (RHD): Glisson's capsule is incised at the base of segment IVb thus exposing the confluence of the right and left hepatic ducts. This can be easily done by continuing the plane already created when the LHD was exposed. This can be continued toward segment V exposing the right anterior and posterior sectoral ducts. Right ductal anatomy can be identified in an easier fashion if a preoperative percutaneous transhepatic biliary stent was placed within the duct.

• Preparation of bile duct for anastomosis: Depending on the classification of injury and its proximity to the hilar plate, the repair technique is chosen. In cases where there is a distal transection greater than 2 cm away from the confluence (E1 injury), the remaining common duct may be debrided and used for the hepaticojejunostomy. For patients with more proximal injuries without separation of the right and left hepatic duct communication (E2-E3), the Hepp-Couinaud approach can be used. This involves incising the LHD horizontally with extension and sometimes across the confluence to the RHD in preparation for a hepaticojejunostomy.[11] For injuries that completely separate the right and left biliary systems, 2 options are available; either separate right and left biliary-enteric anastomoses are performed, or if the 2 ducts are within 1 cm of each other, they can be approximated to form one common channel.

• Creation and preparation of the Roux limb: The jejunum is divided with a linear stapler 30 cm distal to the ligament of Treitz. The Roux limb is brought through the transverse mesocolon to the right of the middle colic vessels and positioned next to the prepared proximal bile duct.

• Creation of the hepaticojejunostomy (there are multiple techniques)
  • End-to-side anastomosis: Can be used for E1-E3 lesions. In E4 lesions the separated right and left hepatic ducts may be approximated into one “double-barrel” duct, and an end-to-side HJ can be performed. E5 lesions will typically require two separate end-to-side anastomoses of both the aberrant right hepatic duct and the main hepatic duct to the jejunum. The technique begins by placing two corner stitches on the right and left sides incorporating at least 3 mm of duct and mucosa of the jejunum. Blumgart published a technique involving placing sutures on the anterior bile duct wall and placing rubber shods on them to retract and expose the posterior aspect of the anastomosis.[12] Next 4-0 or 5-0 interrupted monofilament absorbable sutures are placed to approximate the posterior wall completely. The anterior wall is then completed utilizing the originally placed sutures in a buried knot fashion.
  • Side-to-side anastomosis: A transverse ductotomy is made in the LHD and may be extended into the RHD at the confluence. The open end of the injured main bile duct is then sutured closed with nonabsorbable suture. A side-to-side anastomosis is then performed starting with the posterior wall in an interrupted or running fashion utilizing a 4-0 or 5-0 monofilament absorbable suture.
  • Stenting of the HJ anastomosis is controversial. There has been weak evidence that it prevents HJ anastomotic leaks or strictures and is selectively used according to surgeon preference. Stenting may be done in several ways. An already present PTC biliary stent can be passed from the proximal bile ducts through the anastomosis into the jejunum. Another technique requires placing a Silastic stent through the anastomosis into the proximal bile ducts and then bring it anteriorly through the hepatic parenchyma. A third option is to place a T tube through the anterior wall of the bile duct and having one limb traversing the HJ anastomosis. The long vertical portion is then brought out through the abdominal wall.
  • The cornerstone of the technique is to achieve a tension-free anastomosis.

• Creation of entero-enterostomy: An end-to-side jejunojejunostomy is created with a single layer continuous hand-sewn technique, allowing for an approximately 40 cm bilio-enteric limb length.

• Intraabdominal drain placement and laparotomy closure

Perioperative mortality is reported to be 1.7%, and morbidity is 43%.[5]

The most common early complications are bile leak (5%), intraabdominal abscess (3%), wound infections (8%), and cholangitis (6%). Very few of these patients require intervention and if they do, it is by percutaneous means.[13]

Late complications are primarily comprised of anastomotic stricture formation and recurrent cholangitis which with advancing techniques is highly responsive to endoscopic ballooning and stenting.[14]

Many major bile duct injuries will require surgical repair. There are many described techniques for complex biliary injury repairs including primary repair or primary end to end anastomosis of bile ducts, choledochoduodenostomy, and cholecystojejunostomy. The most popular surgical repair is the Roux-en-Y hepaticojejunostomy. This operation has been consistently superior to the other methods when considering long-term outcomes. There are many different techniques described to perform an RYHJ, and the operating surgeon should choose the method with which he or she is most comfortable or experienced.

Iatrogenic biliary tract injury is a rare but devastating complication of the commonly performed laparoscopic cholecystectomy in the modern age. The extent of the injury can range from mild to severe, and treatments vary according to the injury. Management of bile duct injuries has 3 main goals: control of sepsis, defining and classifying biliary anatomy/injury, and definitive repair of the injury. The bile duct injury is primarily managed by an interprofessional team that includes a surgeon, radiologist, gastroenterologist, infection disease consultant, and an intensivist. These patients usually require close monitoring in an ICU setting by critical care nurses and pharmacists for appropriate pain control and management of nutrition. Repair of bile duct injury is also associated with significant complications that include an anastomotic leak, abdominal abscess, liver failure, wound infections, and cholangitis. The mortality rates depend on the type of injury and comorbidity but can range as high as 20-40%.[15][16][17](Level V)