Anatomic Variations

Any surgeon operating on the biliary tree must be familiar with the wide range of anatomic variations that may be encountered (see Chapter 1B). Anomalies of the cystic duct insertion into the common hepatic duct are most commonly seen (Fig. 42A.1). The cystic duct may join the common hepatic duct quite high, almost at the biliary confluence, or it may run parallel to the common hepatic duct for a long distance before joining it very low, occasionally at the level of the ampulla. In many patients, perhaps 25%, the right hepatic duct per se is absent, and the right anterior and posterior sectoral hepatic ducts join the left hepatic duct independently. In some cases, one of the right sectoral hepatic ducts, usually the anterior, may follow a prolonged extrahepatic course and enter the common hepatic duct quite low, and it may receive drainage from the cystic duct (see Fig. 42A.1D). Such unrecognized, low-entry right sectoral hepatic ducts (Bismuth type 5) are at particular risk of injury during laparoscopic cholecystectomy (Fig. 42A.2; Wherry et al, 1996).

FIGURE 42A.1 Schematic representations of various junctions of the cystic duct with the main extrahepatic biliary channel. A, The cystic duct may join the main bile duct very high, almost at the confluence of the hepatic ducts, or it may run parallel to the common hepatic duct before entering almost at the level of the ampulla of Vater. In this illustration, the right anterior and posterior sectoral hepatic ducts join to form a main right hepatic duct. B, The right anterior and posterior sectoral hepatic ducts may join the left hepatic duct at a common confluence. C, The right anterior and posterior sectoral hepatic ducts may join the left hepatic duct independently. D, The right anterior or posterior sectoral hepatic duct may join the common hepatic duct at a much lower level. The cystic duct may drain into such a duct. Another variation, not shown and probably not relevant for postcholecystectomy injuries, is entry of the right anterior or posterior sectoral hepatic duct into the left hepatic duct.

FIGURE 42A.2 The right anterior sectoral hepatic duct (white arrow) drains into the common hepatic duct, and the right posterior sectoral hepatic duct (black arrow) joins a main left hepatic duct. In this patient, cholecystectomy was accompanied by a biliary injury at the point of confluence of the common hepatic duct and the right anterior sectoral hepatic duct (Bismuth type 5). Repair has been carried out by Roux-en-Y hepaticojejunostomy.

In the future, routine use of preoperative imaging may help minimize bile duct injuries by identifying aberrant biliary anatomy. Already, some centers are examining the utility of preoperative CT cholangiography and MRI in preventing this complication (Hirano et al, 2006). Widespread adoption of this strategy will clearly be costly, but it could be justified: some imaging studies document right ductal aberrancy in the general population ranging from 4.8% to 8.4% (Kullman et al, 1996; Dusunceli et al, 2004). In some cases, the cystic duct is quite short, and misinterpretation of the anatomy can occur easily. Misinterpretation is especially likely if, on intraoperative cholangiography, the catheter has been advanced well into the CBD, and the proximal ducts are not visualized. The surgeon may mistake the common duct for the cystic duct, ligate it, and remove it with the attached gallbladder (Fig. 42A.3). This type of injury seems to be much more common after laparoscopic rather than open cholecystectomy and is well described (Davidoff et al, 1992). A related situation can occur in cases of long-standing cholelithiasis and chronic cholecystitis, resulting in obliteration of the cystic duct, which we will discuss later.

FIGURE 42A.3 A, Operative cholangiogram obtained after cannulation of the cystic duct. The cannula has entered the common bile duct (black arrow), and only the common bile duct has been outlined (white arrow). The common hepatic duct has not been visualized. The surgeon proceeded with cholecystectomy in the belief that he had cannulated the cystic duct. B, The patient became extremely ill after surgery and was referred. Computed tomographic scan revealed massive collections of intraperitoneal bile (arrows), which were drained. C, A subsequent fistulogram revealed a fistulous tract with connections to the right (white arrow) and left abdomen (black arrow). The right anterior sectoral hepatic duct also is seen. The patient, now well and free of jaundice, was monitored. D, Percutaneous transhepatic cholangiography obtained after the patient returned with jaundice showed that the fistula has closed, and a stricture had formed just below the biliary confluence (Bismuth type 3). Repair was performed by Roux-en-Y hepaticojejunostomy using an approach to the left hepatic duct and extending the dissection to the right.

Vascular anomalies also are common, occurring in 20% of patients (see Chapter 1B). In the most common of these, the right hepatic arterial supply arises in part or in whole from the superior mesenteric artery. Such an aberrant vessel usually courses to the right of the portal vein, lateral and posterior to the CBD. During cholecystectomy, this vessel is prone to injury at the junction of the cystic and common hepatic ducts. Vascular injuries are not limited to patients with anatomic anomalies. The classic biliary injury during laparoscopic cholecystectomy, in which the surgeon mistakes the CBD for the cystic duct, is frequently associated with injury to the right hepatic artery, which will be discussed (Davidoff et al, 1992). This problem has been documented to occur in as many as 0.6% of patients after laparoscopic cholecystectomy and may not be apparent at the initial operation but may come to attention later as a hepatic artery pseudoaneurysm (Balsara et al, 1998; Nicholson et al, 1999). Rarely, concomitant vascular injury may involve both the right hepatic artery and right portal vein, which can be life threatening (Fig. 42A.4).

FIGURE 42A.4 A, Transaxial computed tomographic scan without intravenous contrast demonstrating the hypoperfused right lobe (white arrow) and an intraoperatively placed biliary tube (arrowhead). In this patient, the surgeon was confronted with significant bleeding during laparoscopic cholecystectomy and converted to open operation. Bleeding involved the right hepatic artery (HA) and portal vein (PV); these were suture ligated to control the hemorrhage. B, A tube cholangiogram demonstrates the “classic” biliary injury during laparoscopic cholecystectomy: the common bile duct was mistaken for the cystic duct, and a long section of the common duct was excised up to the common hepatic duct (arrow). The arrowhead points to the tube insertion site in the distal common duct. C, Doppler ultrasonography demonstrates lack of flow in both the right HA and PV (arrows).

Ischemia

In the absence of overt injury, delayed biliary stricture formation may result from extensive periductal dissection and consequent interruption of the major ductal arterial supply (see Chapter 1B). Most of the arterial supply to the extrahepatic bile duct is provided by two small arteries that travel along the lateral duct borders in the 3 o’clock and 9 o’clock positions. Sixty percent of the blood supply runs upward from the major inferior vessels (retroduodenal, gastroduodenal), and approximately 38% runs downward from the right hepatic artery (Northover & Terblanche, 1979). Extensive circumferential dissection of the duct may disrupt this axial blood flow and has been proposed as a major mechanism of biliary stricture formation. Although there is no direct evidence to support this, it would seem reasonable not to pursue extensive dissection of the common duct during cholecystectomy. Also, damage to these vessels is likely to be a contributing, if not a central factor, in the formation of strictures attributed to electrocautery use.

Pathologic Factors

Patients with acute cholecystitis may have severe inflammation in the porta hepatis and triangle of Calot, which greatly distorts the anatomy. In addition, the gallbladder is often friable and difficult to grasp, and persistent oozing of blood often obscures the field. Some or all of these factors may conspire to preclude safe laparoscopic cholecystectomy. During the early era of laparoscopic cholecystectomy, acute cholecystitis was considered an absolute contraindication. However, as experience with laparoscopy grew, surgeons became more comfortable extending the indication to include acute cholecystitis. Several reports later documented that the laparoscopic approach not only is possible but also is safe in selected cases of acute cholecystitis (Kum et al, 1996; Wherry et al, 1996; Adamsen et al, 1997; Fletcher et al, 1999; Neri et al, 2003). As a result, laparoscopic cholecystectomy for acute cholecystitis is now widely practiced; in fact, the issue regarding timing of operation (early vs. delayed) has been settled (see Chapter 31; Casillas et al, 2008; Gurusamy et al, 2009). When laparoscopic cholecystectomy is performed for acute cholecystitis, studies have also revealed a greater potential for biliary injury (Kholdebarin et al, 2008). Fletcher and colleagues (1999) reported that complex cases that include patients with acute cholecystitis, cholangitis, and gallstone pancreatitis are associated with a dramatically increased incidence of bile duct injuries (1.7%), although acute cholecystitis alone is not an independent risk factor. Other authors have shown that acute cholecystitis increases the incidence of bile duct injuries twofold to threefold above baseline (Adamsen et al, 1997; Russell et al, 1996; Soderlund et al, 2005). In patients seen initially with acute cholecystitis, we recommend early operation by laparoscopic approach, even in patients with a history of prior open abdominal surgery. Given the increased risk of biliary injury in this setting, however, the threshold for conversion to an open procedure should always be low.

On occasion, the inflammatory reaction is so severe that even conversion to an open procedure does not clarify the anatomy. Fibrosis and inflammation within the triangle of Calot make dissection of the cystic duct particularly hazardous. In severe cases, the gallbladder neck and cystic duct may be fused to the common duct within a sheath of scar tissue. This finding should lead the surgeon away from an extensive dissection to define the cystic duct, which risks a major biliary injury. Placement of a cholecystostomy tube may be a safer approach. An alternative option is partial (subtotal) cholecystectomy with amputation of the gallbladder, well away from the cystic duct/common hepatic duct junction, and placement of a drain. This procedure is generally safe and effective, and in a review of 1100 patients, only 11.2% required operative reintervention (Soleimani et al, 2007). Moreover, centers have reported a significant decrease in the incidence of bile duct injuries since the introduction of laparoscopic subtotal cholecystectomy (Nakajima et al, 2009). In such heavily fibrosed cases, the cystic duct is nearly always obliterated, and postoperative biliary leak is infrequent.

A potentially more difficult problem is the small, contracted, fibrotic gallbladder with extensive surrounding inflammation, sometimes partially embedded into the liver and obliterating the triangle of Calot such that the gallbladder neck and cystic duct are adherent to the common hepatic duct (Fig. 42A.5B). In such cases, the cystic duct is obliterated, and safe dissection in Calot’s triangle is impossible. With long-standing disease, particularly associated with large impacted gallstones in the gallbladder neck, a cholecystocholedochal fistula is possible. A common hepatic duct stricture may be present, resulting from an impacted stone and the subsequent inflammatory response (Mirizzi, 1948; see Chapter 42B). A cholecystocholedochal fistula should be suspected in any patient with gallstones, jaundice, cholangitis, and imaging studies or operative findings that suggest an inflamed and contracted gallbladder. In these cases, an attempt to perform a total cholecystectomy should be abandoned, because this would lead the surgeon directly into the common hepatic duct (Sharma et al, 1998). Rather, partial cholecystectomy with extraction of the stones allows inspection of the depths of the gallbladder and is preferable. A rush of bile into the operative field at this point is strong evidence for a cholecystocholedochal fistula, because the cystic duct is nearly always obliterated. Because a biliary stricture often lies distal to the fistula, direct closure of the defect should be avoided, and it should instead be reconstructed as a cholecystocholedochoduodenostomy (see Chapter 42B and Fig. 42A.5B).

FIGURE 42A.5 A, Obliteration of Calot’s triangle (curved arrow) by the inflammatory process accompanying severe chronic cholecystitis. The gallbladder is contracted around two large gallstones, one of which has eroded into the common hepatic duct, producing a cholecystocholedochal fistula. Such cases often present with obstructive jaundice or cholangitis. Complete cholecystectomy should not be attempted; it inevitably leads to biliary injury. Partial cholecystectomy (dotted line) can be performed with extraction of the calculi. B, Cholecystocholedochoduodenostomy can be done safely and with adequate drainage of bile.

General

Cholecystectomy is performed so commonly that it is easy to adopt a casual attitude toward the procedure; this is unwise, however, because some of these cases can be quite challenging. Also, although it is true that inexperienced or poorly trained surgeons cause many bile duct injuries, as we discussed earlier, even the most well-trained and experienced surgeons can cause an injury. It is imperative, therefore, that the surgeon adhere strictly to the basic tenets of cholecystectomy, either laparoscopic or open, to minimize the risk of biliary injury. Safe cholecystectomy requires clear visualization of the relevant anatomy, which demands proper exposure and modern high-resolution video equipment. Adequate assistance and retraction must be available, the incision must be adequate in length, and any trochars must be properly placed. It is imperative that no structure be ligated or divided unless its identity can be determined unequivocally.

Early reports of laparoscopic biliary injury cited bleeding and subsequent attempts to achieve hemostasis as major contributing factors to bile duct injury (Davidoff et al, 1992; Rossi & Tsao, 1994). At laparoscopy, even a small amount of blood obscures the field and hinders dissection. If necessary, an additional port should be placed for a high-powered suctioner/irrigator to precisely define the site of bleeding. Hemorrhage must be controlled, regardless of the approach, and blind placement of clips or indiscriminate use of electrocautery must be avoided. Early demonstration of the cystic artery is desirable, and it should be divided close to the gallbladder to avoid injury to the right hepatic or common hepatic artery.

Excessive traction on the gallbladder during cholecystectomy may tent the common duct upward, putting it at risk of injury if unrecognized. This mechanism does not seem to be as common at laparoscopic cholecystectomy, although other problems related to retraction may predispose to biliary injury at laparoscopy, which will be discussed later. Some authors have argued that the cystic duct–common hepatic duct junction should be precisely demonstrated before it is ligated and divided, even if this requires separating an adherent cystic duct and tracing it to its termination (Kune & Sali, 1981). We firmly believe that this is unnecessary and potentially hazardous; the risk of biliary injury with such extensive dissection is high and greatly outweighs the risk of a retained cystic duct stone.

The plane of dissection should be maintained as close to the gallbladder wall as possible to avoid entering the liver parenchyma. This is especially important when there is significant inflammation or fibrosis, and the ductal anatomy is unclear. Straying off the gallbladder wall may result in entry into the liver parenchyma and bleeding, further obscuring the field, or injury to a low-entry sectoral hepatic duct or a replaced right hepatic artery. In addition, the major right portal pedicles and branches of middle hepatic vein may be quite superficial in the liver substance with respect to the gallbladder fossa, and damage to these structures can occur if the plane of dissection is too deep. During a difficult open cholecystectomy, the advantage over the laparoscopic approach is that a finger can be inserted into the gallbladder to help define the proper plane.

The observation of bile draining from the gallbladder fossa always suggests the possibility of a biliary injury, perhaps to an aberrant right sectoral hepatic duct. It is tempting to ascribe such a finding to drainage from a subvesical duct of Lushka, a slender, 1- to 2-mm in diameter duct that passes from the right lobe in the gallbladder fossa to join the right hepatic or common hepatic duct (McMahon et al, 1995). In this situation, a major bile duct injury must be considered the leading diagnosis until disproved, and the surgeon is compelled to convert to an open procedure or to place a drain and investigate the cause postoperatively. Regarding the duct of Lushka, although some surgeons question its existence, several detailed anatomic and radiologic imaging studies have reliably identified its structure and course (Kocabiyik et al, 2009). Most patients with bile leaks attributable to a subvesical duct experience a delayed onset of symptoms and are usually seen in the first or second week following the procedure (Fig. 42A.6). In a review of nearly 10,000 patients, the incidence of bile leakage was 0.7%, of which 52% were leaks from subvesical ducts (Spanos & Syrakos, 2006).

FIGURE 42A.6 A, Transaxial computed tomographic scan from a patient 2 weeks after elective laparoscopic cholecystectomy. The arrow points to perihepatic fluid collection consistent with a biloma. B, After percutaneous drainage of the biloma, the patient was evaluated by endoscopic retrograde cholangiopancreatography. The arrow points to the duct of Luschka; the arrowhead demonstrates contrast extravasation.

The utility of routine cystic duct cholangiography is controversial (see Chapter 21), particularly with respect to reducing the incidence of biliary injury at laparoscopic cholecystectomy, which will be discussed later. Occasionally, operative cholangiography reveals a very small CBD with a filling defect, suggesting a small stone. In this situation, simple cholecystectomy without exploration of the common duct is probably safer than operative pursuit of a tiny stone in a small duct. Postoperative endoscopic cholangiography with stone extraction is nearly always possible if subsequently indicated. In general, exploration of a small caliber, otherwise normal-appearing common duct is frequently unrewarding, potentially dangerous, and more likely to result in postoperative symptoms than if such a stone were left in situ. Biliary strictures are more than just a theoretical concern after exploration of a small bile duct (Fig. 42A.7). Rarely, bile duct stones retained after cholecystectomy that are not removable by endoscopic means require reoperation (Fig. 42A.8; see Chapters 35 and 36). Under these circumstances, laparoscopic removal is usually possible via a transcholedochotomy approach (see Chapter 34). If this approach fails, an open exploration can often be avoided by placing a T-tube into the CBD for subsequent operative retrieval by intervential radiology techniques, which are successful in more than 95% of cases (Burhenne, 1980). When indicated at cholecystectomy or after failed attempts by other methods, open exploration of the CBD should be performed through a supraduodenal choledochotomy with careful exposure of a sufficient length of duct but without excessive dissection (see Chapters 29 and 35). Exploration must be gentle and performed only with soft bougies, Fogarty-type balloon catheters, or a choledochoscope (rigid or flexible). Metal bougies such as Bake’s dilators or stone forceps should be used with caution and should never be forced through the papilla of Vater into the duodenum; otherwise, secondary postinflammatory papillary stenosis may occur, or a false passage into the duodenum or pancreas may be created. After bile duct exploration, the choledochotomy should be closed with care, because this is also a potential source of biliary stricture (see Chapters 29 and 35).

FIGURE 42A.7 A, Cystic duct cholangiogram obtained at cholecystectomy. A stone was suspected in a small-caliber common bile duct. Bile duct exploration was performed, but no stone was identified. B, Postoperatively, the patient developed recurrent attacks of cholangitis. Endoscopic cholangiogram showed a bile duct stricture at the previous choledochotomy site (arrow).

FIGURE 42A.8 Maximum intensity projection magnetic resonance cholangiopancreatographic, T2-weighed image demonstrates a large retained stone (arrowhead) within the common bile duct. This patient had previously undergone laparoscopic cholecystectomy and did not respond to postoperative removal by endoscopic means. The arrow points to cystic duct remnant.

Transduodenal sphincteroplasty probably is best reserved for patients with stones impacted in the distal bile duct (see Chapters 29 and 35). Stenosis or stricture of the distal CBD may occur after surgical or endoscopic sphincteroplasty or sphincterotomy. Side-to-side choledochoduodenostomy is an option that should be considered in patients with multiple stones, primary stasis stones, or distal obstruction by stricture or papillary stenosis. The results are generally good, provided that the CBD is dilated to at least 15 mm in diameter, and a stoma of at least 2 cm can be created (Schein & Gliedman, 1981). Choledochoduodenostomy performed to a decompressed duct is more likely to result in stricture formation and cholangitis (see Chapter 29; Johnson & Stevens, 1969).

Laparoscopic-Specific Factors

Several technical factors specific to laparoscopic cholecystectomy predispose to biliary injury (see Chapter 34). Mistaking the common duct for the cystic duct is a frequent technical error (Davidoff et al, 1992; Gigot et al, 1997; Olsen, 1997). In the most common sequence of events, a long length of the common duct is excised up to the proximal common hepatic duct, which is either occluded or left to drain bile into the peritoneal cavity. This devastating injury—referred to as the “classic” laparoscopic injury, rarely seen at open cholecystectomy—also may be associated with damage to the right hepatic artery (Davidoff et al, 1992; Strasberg et al, 1995). Less severe injuries also may occur, such as lacerations of the duct wall or near-complete transections. Proper exposure is essential to avoid injuries arising from such anatomic misinterpretations. Maximum cephalad traction on the gallbladder fundus is necessary to expose the cystic duct and triangle of Calot. Concomitant lateral traction on the infundibulum is equally important, however, to open the angle between the cystic and common hepatic ducts. If lateral traction is inadequate, Calot’s triangle is not opened sufficiently, and the course of the common duct is placed directly in line with that of the cystic duct (Fig. 42A.9; Rossi & Tsao, 1994; McMahon et al, 1995). The common duct may be damaged during dissection of the cystic duct because of its proximity, or because it is misidentified. Before any structures are divided, Calot’s triangle must be cleared of all fatty and areolar tissue. The peritoneal reflection along the posterolateral aspect of the gallbladder should be opened to fully expose the junction of the gallbladder neck and cystic duct. At the completion of the dissection, only the cystic artery and cystic duct should be seen entering the gallbladder, and the bottom of the gallbladder fossa should be visible. The use of a 30-degree laparoscope has been advocated to improve visualization of this area (Hunter, 1991), and the resulting anatomically satisfying final view has been described by Strasberg (1995) as the “critical view of safety.” The dissection should be maintained close to the gallbladder wall, and the cystic duct should be divided as close as possible to its junction with the gallbladder.

FIGURE 42A.9 Area of the triangle of Calot as it appears during laparoscopic cholecystectomy. A, Upward traction on the gallbladder, with insufficient lateral traction on the infundibulum, fails to open Calot’s triangle adequately. This causes the cystic duct (CD) and common hepatic duct (CHD) to become aligned within the same plane. Injury to the CHD can occur during dissection of the CD because of its proximity or as a result of mistaking the CHD for the CD. B, Proper lateral traction on the infundibulum opens Calot’s triangle, allowing safer dissection of the CD. In some cases, obliteration of Calot’s triangle by dense fibrosis prevents adequate exposure of this area, even with adequate traction (see Fig. 42A.5).

Routine intraoperative cholangiography has been advocated by many to minimize the incidence of laparoscopic biliary injuries (Way, 1992; Moossa et al, 1992; Asbun et al, 1993), but it remains controversial. In a meta-analysis encompassing more than 327,000 laparoscopic cholecystectomies, Ludwig and colleagues (2002) noted contribution of intraoperative cholangiography to incidence and outcome of CBD injuries during laparoscopic cholecystectomy and found injury rates to be halved in a routine cholangiogram group (0.21%) compared with a selective group (0.43%). A valid concern regarding the conclusions from these studies is that surgeons who use selective cholangiography do so appropriately in situations of inflammation or unclear anatomy inherently associated with increased risk of bile duct injuries. Thus, the injury rate under these circumstances can be artificially elevated, because the denominator—that is, the number cholecystectomies done without cholangiogram—is not typically included in the overall analysis. In a large review of cholecystectomies from Western Australia, Fletcher and colleagues (1999) reported that intraoperative cholangiography reduced the incidence of biliary injury twofold overall and eightfold in complex cases (acute cholecystitis, cholangitis, pancreatitis). In addition, some authors noted a strong inverse correlation between biliary injury and nonperformance of cholangiography (Torkington et al, 1999). Cholangiography is clearly not preventive if the injury occurs after a normal study, or if the study serves only to identify an injury that already has been inflicted (Andren-Sandberg et al, 1985).

Other groups, however, have touted the lack of statistical benefit with the routine use of intraoperative cholangiography. A survey analysis of more than 184 Italian hospitals accounting for more than 56,000 operations demonstrated no significant difference between bile duct injury rate when cholangiogram was used routinely or selectively (Nuzzo et al, 2005). In contrast, several other reports have suggested that routine cholangiography may not reduce the incidence of biliary injury but may minimize injury severity and allow immediate recognition and definitive repair (Gigot et al, 1997; Woods et al, 1994; Carroll et al, 1996; Russell et al, 1996); this depends on proper interpretation of the study. In a review of 177 biliary injuries, Olsen (1997) found that only two of 32 cholangiographies were correctly interpreted, despite evidence of impending bile duct transection in most. The most common error was accepting an incomplete study as normal, without opacification of the right and left hepatic ducts. In a similar study, Stewart and Way (2003) showed that in their series of 252 bile duct injuries, cholangiograms were obtained in 43 patients, but only nine were correctly interpreted intraoperatively. They concluded that these injuries stemmed from a misperception that was often so compelling that adjunctive cholangiographic data was likewise misperceived. Failure to opacify the proximal bile ducts in their entirety should prompt the surgeon to strongly consider open conversion. Laparoscopic ultrasound has been described as an alternative to cholangiography for delineation of the cystic duct and identification of common duct calculi (Tomonaga et al, 1999). Recent studies demonstrate the efficacy of the technique as an alternative to cholangiography (Machi et al, 2009; Hublet et al, 2009), but it is not widely used.

Bile leakage occurs with greater frequency after laparoscopic cholecystectomy than after open cholecystectomy, which may be related to the use of clips rather than ties or suture ligatures (McMahon et al, 1995). Clips are less secure than sutures and may become dislodged if improperly placed or if manipulated after placement (Nelson et al, 1992; Fig. 42A.10). Reports of clip migration leading to complications such as choledocholithiasis and pancreatitis have also been reported (Raoul et al, 1992; Cetta et al, 1997; Dolay et al, 2007). Also, incomplete occlusion may occur if clips are placed across a thickened, rigid cystic duct or a cystic duct containing stones or if other tissues are included. When placing clips, it is important that the tips meet to ensure adequate occlusion. If both tips cannot be visualized as the clip is being applied, damage to adjacent structures may occur. If the clip does not fit across the entire width of the cystic duct, the surgeon must consider the possibility that the structure about to be divided is not the cystic duct but the common duct. If the anatomy is clear, and the cystic duct is simply thickened, placement of a ligature may be more appropriate (Michalowski et al, 1998). Also, using electrocautery in areas adjacent to clips should be avoided, because this may result in conduction of thermal energy to the adjacent common duct and lead to delayed biliary structure.

FIGURE 42A.10 Percutaneous transhepatic cholangiography on a patient who underwent laparoscopic cholecystectomy. A previously placed endoluminal stent failed to control bile leakage from the cystic duct stump (arrow). Note the percutaneous drain situated near the cystic duct remnant and the enteric feeding tube in the duodenum. This patient was managed nonoperatively.

Fibrosis

Biliary obstruction is associated with the formation of high local concentrations of bile salts at the canalicular membrane, and these initiate pathologic changes in the liver (Schaffner et al, 1971). Bile thrombi form within dilated centrilobular bile canaliculi, and secondary changes develop in adjacent hepatocytes. A complex cascade of molecular and cellular events ensues, collectively termed fibrogenesis (Friedman, 2008), which ultimately leads to the deposition of collagen and other extracellular matrix proteins and eventually to fibrosis and scarring around bile ducts and ductules (Maher & McGuire, 1990; Jarnagin et al, 1994; Friedman, 1997; see Chapter 6). As this process progresses, mechanical interference with bile flow develops in these intrahepatic biliary radicles and perpetuates cholestasis.

Fibrosis is accompanied by liver cell hyperplasia (Weinbren et al, 1985); this is not true in secondary biliary cirrhosis, because the lobular structure of the liver is usually well preserved (Fig. 42A.14) and the marked fibrosis that occurs in advanced cases only rarely progresses to true cirrhosis. This knowledge is important in planning therapy because many of these pathologic changes are reversible (Duffield et al, 2005). A histologic return of normal liver parenchyma is seen after relief of obstruction in both animal and human models (Sikora et al, 2008; Kirkland et al, 2009), which correlates to the return to near-normal liver function after relief of biliary obstruction (Blumgart, 1978). Fibrosis also may develop in the extrahepatic ducts proximal to the stricture, which is especially likely after biliary intubation. Upward retraction of the ducts is accompanied by a sequence of mucosal atrophy, squamous metaplasia, inflammatory infiltration, and further fibrosis in the subepithelial layers of the ducts.

FIGURE 42A.14 A, Photomicrograph showing the effect of long-standing biliary obstruction secondary to benign biliary stricture. Hepatic fibrosis is present, but with preservation of the basic hepatic architecture, with the portal tract (white arrow) and hepatic venous radicles (black arrows) maintaining their normal relationships. The fibrosis extends between the lobules, but the pattern is not one of true cirrhosis, in which there is destruction of the basic hepatic architecture. B, Extensive fibrosis with a substantially normal relationship of hepatic venous radicles (black arrows) to portal tracts (white arrow) in a patient with portal hypertension.

(From Weinbren K, et al, 1985: Structural aspects of the liver in patients with biliary disease and portal hypertension. J Clin Pathol 38:1013-1020.)

It usually takes several years for liver fibrosis and portal hypertension (see Chapter 70A, Chapter 70B ) to become evident, although it may manifest 2 years after the development of the stricture. Major stigmata of hepatocellular dysfunction, such as spider angiomata and encephalopathy, are uncommon in benign biliary obstruction and should raise the possibility of preexisting parenchymal disease (e.g., chronic hepatitis, alcoholic liver disease). If liver biopsy reveals significant primary hepatocellular disease in association with a benign stricture, the prognosis is especially poor.

Atrophy

The distribution of liver mass is regulated by a poorly understood balance of bile flow, portal venous flow, and hepatic venous flow. Segmental or lobar atrophy may result from portal venous obstruction or bile duct occlusion in the affected area (see Chapter 5). Unilobar atrophy is associated with hypertrophy of the contralateral lobe and may present diagnostic and operative difficulties. Liver lobe atrophy and compensatory hypertrophy is frequently found in benign strictures and may be associated with asymmetric involvement of lobar or sectoral hepatic ducts, interference with portal venous blood supply, or decreased portal perfusion owing to secondary fibrosis. In benign strictures, the dilated ducts within the atrophic segments often are filled with infected bile and debris, and even though drainage of an atrophic segment would not be effective in relieving jaundice, cholangitis may continue unabated unless satisfactory drainage of the atrophic and hypertrophic segments is achieved.

The presence of significant atrophy and compensatory hypertrophy greatly influences the approach to repair. The most common situation is gross hypertrophy of the left lobe accompanied by right lobe atrophy (Czerniak et al, 1986). Anastomosis in the region of the hilum is made difficult by the rotational deformity and anatomic distortion imposed by this condition (see Chapters 5 and 29). A thoracoabdominal approach to such strictures provides more direct exposure and access for repair by allowing rotation of the liver to the left (Bismuth & Lazorthes, 1981). Recent reports verify that the presence of atrophy and contralateral hypertrophy are associated with significantly longer reconstructive operations, higher intraoperative blood loss, and greater blood transfusion requirements (Pottakkat et al, 2009). Similar problems may occur in bile duct strictures after right hepatic resection.

Portal Hypertension (See Chapter 70A, Chapter 70B )

It is estimated that approximately 15% to 20% of patients with benign biliary stricture have concomitant portal hypertension (Blumgart & Kelley, 1984; Chapman et al, 1995). Patients with biliary strictures may develop portal hypertension as a result of secondary hepatic fibrosis or direct damage to the portal vein. Alternatively, portal hypertension may be due to preexisting liver disease. It is important that these patients undergo further workup, including a liver biopsy, to exclude underlying chronic parenchymal disease. Iatrogenic biliary injuries are often the subject of medicolegal proceedings, and precise documentation of all injuries is essential to provide an accurate assessment of the cause of symptoms and prognosis. The outcome of patients with biliary strictures and portal hypertension is much worse than for patients without portal hypertension, with an in-hospital mortality rate of 25% to 40% (Blumgart & Kelley, 1984; Chapman et al, 1995). It has been suggested, however, that adequate biliary drainage may be followed by some resolution of fibrosis and perhaps a reduction in portal pressure (Blumgart, 1978).

Radiologic Investigations (See Chapter 13, Chapter 15, Chapter 16, Chapter 17, Chapter 17 )

Duplex ultrasonography is an excellent, noninvasive means of showing intrahepatic ductal dilation and may reveal a subhepatic fluid collection or evidence of vascular damage. Although ultrasound may provide valuable information regarding the level of biliary injury, it is of little value in assessing the extent of a stricture and is of no value if the biliary tree is decompressed.

Computed tomography (CT) is probably the best initial study, the results of which help direct further investigations. A good quality CT scan shows a dilated biliary tree and helps localize the level of ductal obstruction in patients with strictures. In addition, CT identifies fluid collections or ascites, which may suggest the possibility of vascular damage, and it reveals lobar atrophy.

In patients with biliary strictures, complete delineation of the level and extent of injury is necessary. All branches of the right and left intrahepatic biliary tree must be outlined, particularly in cases of high bile duct stricture and recurrent stricture after previous reconstruction. Displaying the hepatic duct confluence (if intact) and the left ductal system and its branches is especially important in selecting the appropriate reconstruction. Percutaneous transhepatic cholangiography (PTC) is much more likely than endoscopic retrograde cholangiopancreatography (ERCP) to provide this information, and PTC remains the standard investigation in this setting (Fig. 42A.15). Drainage catheters should be left in place following PTC if a complex injury is identified on cholangiogram, because palpation of the catheter intraoperatively often helps guide identification of ductal structures later during definitive repair. The risk of cholangitis can be reduced with prophylactic antibiotics.

FIGURE 42A.15 Percutaneous transhepatic cholangiography showing a surgical clip occluding the common hepatic duct just below the confluence (arrow). All major branches of the proximal biliary tree are outlined.

Magnetic resonance cholangiopancreatography (MRCP) has emerged as a valuable tool in evaluating proximal bile duct injuries (Coakley et al, 1998). This noninvasive modality provides striking images of the biliary tree and yields anatomic information in a single study that was previously obtainable only with CT and PTC (Fig. 42A.16). Multiple studies have now confirmed the high accuracy and detailed information provided by MRCP (Bujanda et al, 2003; Jarnagin et al, 1994; Ragozzino et al, 2004). However, in some cases involving severely distorted anatomy as a result of atrophy, hypertrophy, or dense scarring, preoperative PTC and catheter placement should still be strongly considered, not only for additional cholangiographic information or intraoperative guidance but also because catheters can be easily exchanged for soft tubing to stent across worrisome small caliber anastomoses.

FIGURE 42A.16 A, Coronal single-shot fast spin-echo magnetic resonance cholangiopancreatography (MRCP) showing a surgical clip (arrow) occluding the common hepatic duct just below the confluence. B, Coronal single-shot fast spin-echo MRCP in a young woman with recurrent cholangitis after multiple attempts to repair a postcholecystectomy bile duct injury. The hepatic duct confluence (white arrow) is shown. Excess fluid was noted in the adjacent colon (black arrow), suggesting a fistula from the biliary tree to the hepatic flexure. Surgical findings confirmed a fistula from the right posterior sectoral hepatic duct, which had been excluded from the anastomosis.

(From Coakley FV et al, 1998: Complex postcholecystectomy biliary disorders: preliminary experience with evaluation by means of breath-hold MR cholangiography. Radiology 209:141-146.)

ERCP is seldom of value in the precise diagnosis of complete proximal bile duct strictures because there is often discontinuity of the CBD preventing visualization of the intrahepatic ductal system. ERCP may be more helpful for incomplete strictures (stenoses) and is appropriate for patients with a history of sphincteric damage at previous common duct exploration, or if there is suspicion of papillary stenosis or other periampullary pathology. ERCP also has a role in the diagnosis and treatment of patients with bile leakage from the cystic duct stump or from a laceration of the common duct (Brooks et al, 1993). These patients have evidence of an intraabdominal fluid collection on CT. After percutaneous drainage, biliary scintigraphy (e.g., hepatobiliary iminodiacetic acid [HIDA] scan) can be used to establish the presence of a persistent bile leak. ERCP may then be applied to identify the location of the leak, and placement of a stent may reduce or eliminate bile leakage; however, many bile leaks resolve with percutaneous drainage alone, and ERCP is probably unnecessary in the absence of radiographic or clinical evidence of ongoing bile drainage (Brooks et al, 1993).

Isotopic scanning techniques may be valuable in assessing bile duct strictures, particularly the functional assessment of incomplete strictures, previous biliary reconstructions, and isolated sectoral hepatic duct strictures (see Chapter 15). HIDA scanning offers a dynamic and quantitative assessment of liver function and of the clearance of bile across anastomoses and stenoses (Fig. 42A.17; McPherson et al, 1982). In patients with hepatocellular disease, HIDA scanning may be valuable in distinguishing the contribution of the biliary obstruction from that of the intrinsic liver disease to the overall biochemical and symptomatic picture. In such cases, the bilirubin level may be normal, but the alkaline phosphatase level is increased. HIDA scanning also is valuable during follow-up of patients after surgical repair. Because it can be repeated and is noninvasive, it is of particular value in showing anastomotic patency and function when no tube has been left across the anastomosis at the time of repair (see Fig. 42A.17). An isolated sectoral hepatic duct stricture is suggested by delayed clearance of isotope from a portion of the liver.

FIGURE 42A.17 A, Hepatobiliary iminodiacetic acid (HIDA) scan, anterior view of the liver 5 minutes after the intravenous injection of 5 mCi of technetium 99m–Choletec in a patient after right hepatectomy and hepaticojejunostomy for a benign stricture. This shows rapid visualization of liver with slight heterogenous distribution of the tracer throughout the liver, major bile ducts, and early filling of the Roux-en-Y limb. B, Additional single-photon emission computed tomography of the liver was obtained (upper panels). Arrows in the fused nuclear medicine (NM) and computed tomographic (CT) images correspond to high levels of γ-radiation emission; lower panels correspond to the HIDA scan with 1-minute sequential frames in the same patient.

Arteriography and delayed-phase portography (see Chapter 19) can be obtained to confirm vascular injury on the initial studies, a suspicion of portal hypertension from the history and physical examination, or a history of excessive bleeding at the time of cholecystectomy (Li et al, 2008). A biliary injury in the setting of portal hypertension dramatically increases the morbidity and mortality of operative intervention, and its presence should redirect the management approach (Chapman et al, 1995). The combination of biliary and vascular injuries often leads to segmental or lobar atrophy, but it may also be seen with long-standing biliary obstruction alone. An atrophic lobe may be evident on the initial ultrasound or CT scan and appears as a small, often hypoperfused area with dilated, irregular, and crowded bile ducts (Fig. 42A.18). Isotopic scanning may show what appears to be a filling defect in the affected area. It is important to recognize lobar atrophy on the cross-sectional imaging studies, not only because it is an indicator of concomitant vascular injury needing further evaluation, but also because it would change the operative approach during repair (see Chapter 29). In addition, patients with combined bile duct and hepatic artery injuries seem to be at increased risk for severe complications, such as hepatic necrosis and abscess, after reconstructive surgery. A patient undergoing biliary reconstruction in the setting of hepatic artery occlusion may also be at greater risk of late stricture recurrence (Gupta et al, 1998; Schmidt et al, 2005).

FIGURE 42A.18 Computed tomographic scan showing severe atrophy of the right lobe. The right lobe is hypoperfused and small and is clearly demarcated from the left lobe (black line). Notice the markedly increased size of segment IV and the left lateral segment (white line) and the dilated and crowded ducts in the small right lobe.

Occasionally, injection of contrast material into an established biliary fistula or percutaneous drain outlines the ductal system (Fig. 42A.19). Such studies may complement information provided by formal PTC, particularly if the fistula or tube tract drains an excluded sectoral duct (see Chapter 42B). Because bacterial colonization or biliary infection is inevitable in such cases, it is wise to administer prophylactic antibiotics before and after these studies.

FIGURE 42A.19 Injection of contrast material into a tube that had been placed into the ductal system after a hilar ductal injury recognized at operation. The patient was referred draining approximately 200 mL of bile per day, but with normal liver function test (LFT) results and no fever. The tube was passed into the right hepatic ductal system, but filling of the entire intrahepatic biliary tree is seen with what appears to be a complete division of the common hepatic duct; a fistulous connection has developed between the left hepatic ductal system and the common hepatic duct. The tube was withdrawn and no repair was performed. Subsequent atrophy of the right liver occurred, but the patient was well and symptom free with normal LFT results over a 4-year follow-up period.

Preoperative Preparation

In general, operative repair of bile duct injuries need not be rushed, the exceptions being treatment of bile duct injuries recognized at the time of initial cholecystectomy or, rarely, emergency treatment of suppurative cholangitis or peritonitis. For most patients, there is ample time to treat coexisting conditions and to perform a full investigation, both of which increase the likelihood of a successful outcome (Stewart & Way, 1995; Chapman et al, 1995).

Cholangitis is a frequent occurrence in patients with bile duct strictures, especially after ductal intubation (see Chapter 43). Administration of intravenous antibiotics is important prior to surgical treatment, and the results from bile cultures obtained at PTC should be used to direct therapy. Patients with severe cholangitis and sepsis are unlikely to respond to antibiotics alone and should be submitted to percutaneous drainage before surgery. Preoperative antibiotics are usually adequate to manage milder attacks and should be used in patients with no clinical evidence of cholangitis, given the high incidence of bacterial contamination. Antibiotic regimens should take into account the frequent presence of anaerobic organisms and enterococci in patients with biliary obstruction (Thompson et al, 1990; Hochwald et al, 1999). We begin antibiotics immediately before operation and continue appropriate treatment for 5 to 7 days postoperatively if cholangitis is a preoperative feature. Although no firm data exist to guide the duration of treatment, the markedly increased incidence of postoperative infectious complications in patients with endoscopic or percutaneous stents suggests that a prolonged course of treatment is justified (Hochwald et al, 1999). These data further suggest that jaundice without evidence of cholangitis is not an indication for biliary intubation.

Anemia should be corrected, if necessary, by blood transfusion; coagulation defects, which typically manifest as a prolongation of the prothrombin time, should be treated with vitamin K or fresh frozen plasma. Patients with prolonged illness may be seen with malnutrition (see Chapter 24). Enteral feedings through a fine-bore nasal catheter may be successful in some cases but may not be tolerated in sufficient amounts, and parenteral nutrition may be necessary. Despite these measures, however, weight gain is sometimes difficult to achieve, and to date no prospective randomized trials have shown a benefit from short-term preoperative nutritional support. A significant external bile fistula predisposes to excessive fluid and electrolyte loss and may lead to hyponatremia and acidosis (McPherson et al, 1982). It is imperative to correct fluid deficits and electrolyte imbalances before operation (see Chapter 24).

The preoperative management of complications of biliary injuries, such as biliary peritonitis, subphrenic or subhepatic abscess, hemorrhage from erosive gastritis or esophageal varices, or hepatic failure secondary to fibrosis, is important; usually, these must be addressed before biliary reconstruction can be considered. In general, drainage of intraabdominal abscesses and control of gastrointestinal hemorrhage takes priority; however, if systemic sepsis arises from an obstructed biliary tree, a factor that may contribute to other complications, immediate biliary drainage is essential. In such desperately ill patients, it is preferable to perform rapid percutaneous drainage to allow further resuscitative measures with intravenous antibiotics and hydration to prevent renal insufficiency. Management of portal hypertension and external bile fistula occurring in association with stricture is addressed subsequently.

Surgical Treatment

The most appropriate management of bile duct injuries depends on the injury type and whether or not the injury is diagnosed immediately or at some time after operation.

Injury Recognized at Initial Operation

If injury to the extrahepatic biliary tree is recognized at the time of initial cholecystectomy, the surgeon should consider his or her experience and ability to repair it immediately. The advice of a more experienced surgeon should be sought if possible. The situation is not immediately desperate, and there is always time to wait a short while for another opinion and for additional assistance. Substantial evidence suggests that immediate open conversion and repair by an experienced surgeon is associated with reduced morbidity, shorter duration of illness, and lower cost (Stewart & Way, 1995; Savader et al, 1997). A recent multivariate analysis of bile duct injuries by Stewart and Way (2009) identified timing of biliary reconstruction as being insignificant when patient preoperative condition, complete cholangiography, surgical technique, and surgeon experience are optimized.

Despite the apparent ability to perform biliary reconstruction electively, several studies have cited the benefits of early referral to a tertiary center, as such institutions have specialized hepatobiliary surgeons and radiologists to diagnose and treat biliary complications in a timely fashion (Sicklick et al, 2005; Fischer et al, 2009). Each failed repair is associated with some loss of bile duct length (Tocchi et al, 1996) and greatly exacerbates an already difficult situation. This is particularly true of injuries involving the biliary confluence, in which failure of the initial repair and loss of bile duct length may result in isolation of the right and left hepatic ducts; repair becomes more difficult, and the likelihood of a successful outcome is reduced (Chapman et al, 1995). If the surgeon cannot effect a reasonable repair, and competent help is unavailable, drains should be placed to control any biliary leak, and the patient should be referred to a specialist center.

The damaged area of bile duct requires careful dissection to define the extent of injury. To accomplish this dissection without making matters worse, the laparoscopic approach must be abandoned in favor of a generous right subcostal, extended subcostal, or chevron incision. Additional assistance should be obtained to aid in exposure. Operative cholangiography may be helpful at this point to delineate the anatomy and the type of injury. Regardless of the location of the lesion, initial repair of the damage recognized at the time of cholecystectomy should have two basic aims: 1) maintenance of ductal length below the hilus without sacrifice of tissue and 2) avoidance of uncontrolled postoperative bile leakage.

The initial intervention may not be the final definitive reconstruction; this is particularly true of injury to small ducts that may be difficult to repair. The prime aims of maintaining length and preventing fistulation should guide the surgeon, rather than elaborate attempts at reconstruction under adverse circumstances. It is probably safer to provide external drainage by means of a tube inserted proximally into the bile duct and to refer the patient for specialist treatment, rather than to complicate the situation with a repair that is likely to fail and lead to further damage.

The injury in most cases involves complete transection with or without excision of a length of common duct. Occasionally, only an aberrant right sectoral hepatic duct is involved (Bismuth type 5), although this too may be associated with concomitant injury to the common hepatic duct or CBD. Durable reestablishment of biliary-enteric continuity is difficult when the ducts are small and decompressed, and referral to a specialist unit is crucial in this situation.

Two options are available for repairing a complete duct transection. The first is end-to-end repair over a T-tube. This repair is feasible only if the transected ends can be apposed without tension, which usually requires full mobilization of the duodenum and head of the pancreas. The anastomosis is created using a single layer of interrupted absorbable sutures with the T-tube brought out of the bile duct away from the anastomotic line. Silk sutures should be avoided for all biliary reconstructions, because they can promote an inflammatory reaction and act as a nidus for stone formation. End-to-end anastomoses are associated with a high incidence of late stricture formation, up to 60% (Csendes et al, 1989; Pellegrini et al, 1984; Rossi & Tsao, 1994; Stewart & Way, 1995). Other reports support the use of end-to-end repair, because more than two thirds of the associated complications, such as stricture or leak, can be managed nonoperatively (de Reuver et al, 2007). In general, we recommend Roux-en-Y hepaticojejunostomy, which will be discussed later; this approach is more likely to give better long-term results.

An injury to the lateral duct wall may be amenable to direct suture repair, and relatively small and simple lacerations may be repaired with interrupted 4-0 or 5-0 absorbable suture. The area of injury should be adequately exposed, but extensive dissection risks further injury and late stricture formation. Some authors recommend T-tubes for all such repairs, but they are probably unnecessary for small lacerations, and their placement into a decompressed bile duct may exacerbate the injury (Rossi & Tsao, 1994). An analogous situation is primary choledochorrhaphy after CBD exploration, and several authors have reported excellent results without using T-tubes (Sheen-Chen & Chou, 1990; Sorensen et al, 1994; Tu et al, 1999). Long, lateral injuries that are not circumferential may be impossible to repair transversely without compromising the lumen, and direct repair over a T-tube is likely to result in future stenosis. Some authors have suggested that vein patches may be used to cover such defects (Ellis & Hoile, 1980), whereas others have described using the cystic duct stump or pedicled flaps of jejunum (Okamura et al, 1985).

Although these approaches may have merit in some situations, we prefer instead to use a Roux-en-Y loop of jejunum as a serosal patch (Fig. 42A.20). A T-tube is placed across the defect, and its long limb is led out through the Roux loop and exteriorized through the abdominal wall. This approach has several advantages: First, bile duct length is maintained. Second, the jejunal serosa is used to cover the defect, secured in place with fine, interrupted absorbable sutures to the bile duct wall without attempting direct approaches to the ragged edge of the damaged duct. Finally, the T-tube provides biliary decompression across the jejunum so that when it is removed, any leaking bile drains into the bowel lumen rather than the abdominal cavity. This method may be particularly useful to an inexperienced surgeon in a difficult situation.

FIGURE 42A.20 Method of repair of a noncircumferential laceration to the bile duct wall. A, Injury is lateral with loss of ductal wall over some considerable length. B, A Roux-en-Y loop of jejunum is prepared and brought up. A T-tube is placed within the injured bile duct, and the long limb is led out across the jejunal loop, which is secured to the bile duct as a serosal patch over the defect.

Technical Approaches to Biliary Repair (See Chapter 29)

Biliary-Enteric Repair

For most cases of bile duct transection or stricture, biliary-enteric anastomosis is the procedure of choice. For strictures of the retropancreatic or immediate supraduodenal portion of the CBD, choledochoduodenostomy is an ideal procedure. The anastomosis may be performed either side-to-side or end-to-side (see Chapter 29). This technique is appropriate only in the setting of a dilated bile duct and almost certainly would result in recurrent stricture if created to a decompressed duct. Most postcholecystectomy strictures are not amenable to choledochoduodenostomy, because such low injuries are unusual in contrast to postgastrectomy strictures, which often involve the distal bile duct. Strictures involving the common hepatic duct are more difficult to manage, especially strictures involving the biliary confluence, and they almost always require Roux-en-Y hepaticojejunostomy for reconstruction. The technical aspects of biliary-enteric anastomosis have been described (Voyles & Blumgart, 1982; Blumgart & Kelley, 1984) and are outlined in Chapter 29.

There are a variety of approaches to the proximal hepatic ducts. When the stricture is below the confluence (Bismuth type 1 or 2), a direct anastomosis to the hepatic duct stump is usually straightforward. By contrast, when the stricture encroaches on the confluence of the right and left hepatic ducts (type 3) or extends proximally so as to isolate the ducts (type 4), the problem becomes more complex, and good results are more difficult to achieve. The choice of surgical approach should be tailored to the height and extent of the lesion. The technical descriptions that follow should be read in conjunction with Chapter 29.

An important feature is early division of the falciform ligament back to the diaphragm and freeing the liver of adhesions. Dissection should begin in the right subhepatic area, and it is usually necessary to mobilize completely the hepatic flexure of the colon, starting from below and working upward and medially. The duodenum often adheres to the undersurface of the liver and to the hilar structures, particularly in the area of the stricture. The surgeon may encounter an internal bile fistula to the duodenum or may injure the duodenal wall during this portion of the dissection, either of which would require repair.

Attempts to identify the duct below the stricture are unnecessary, because the distal duct generally cannot be used for anastomosis; it is usually encased in dense scar tissue, and extensive dissection to free it risks injury to the hepatic artery and portal vein. The essential point is identification of the bile ducts proximal to the stricture, and a systematic, careful, and patient approach is necessary. Dissection in the area lateral to the hepatic artery pulsation allows identification of the common hepatic duct. Although this approach is reasonable in patients with relatively low strictures (Bismuth type 1), it is inappropriate in most cases. It is generally much easier and safer to expose the left hepatic duct by lowering the hilar plate at the base of segment IV (quadrate lobe). Often this area has not been disturbed by the previous surgeon and is likely to be relatively free of adhesions. This maneuver delivers the left hepatic duct and the biliary confluence from the undersurface of the liver and makes identification of the strictured area much easier. Adhesions posterior to a damaged duct may be dense, and extensive dissection in this situation risks injury to the underlying portal vein. It is generally unnecessary to come around the scarred area completely, provided that the posterior wall of the duct above the stricture can be elevated sufficiently for anastomosis.

Strictures at or above the level of the biliary confluence are much more challenging. Adequate exposure of the bile ducts is usually achievable by dissecting the left hepatic duct system. This approach is based on the anatomic studies of Couinaud (1953, 1955; Hepp & Couinaud, 1956) and is well described (Bismuth et al, 1978; Blumgart & Kelley, 1984). For type 2 and type 3 strictures, biliary-enteric anastomosis to the left hepatic duct provides complete drainage of the left and right ductal systems. For type 4 strictures, however, the confluence is obliterated, and it is necessary to provide drainage of the right lobe as well, often by dissection across the stricture and creation of a second anastomosis to the right ductal system. Occasionally, mobilization or even partial excision of the quadrate lobe may be necessary in some type 4 strictures.

Although most high strictures may be approached and managed as described previously, it is occasionally difficult to expose the left hepatic duct because of adhesions or fibrosis. Excessive bleeding may be encountered, or a large, overhanging quadrate lobe may prevent access to the left duct. Occasionally, the extrahepatic length of the left duct, normally much greater than the right, is short, and access to it is difficult. In such instances, repair can be accomplished by dissection of the left duct within the umbilical fissure, known as the ligamentum teres or round ligament approach (Fig. 42A.21; Soupault & Couinaud, 1957). This approach rarely is indicated for benign strictures and should not be used unless the biliary confluence is intact, so that a left-sided anastomosis would drain the entire liver.

FIGURE 42A.21 Roux-en-Y hepaticojejunostomy to the segment III duct after postcholecystectomy stricture initially treated by hepaticojejunostomy, using the mucosal graft technique with a transhepatic tube through the right liver. At referral, the patient had a grossly atrophic right lobe and a high bile duct stricture (black arrow). At operation, the left hepatic duct was exposed using the ligamentum teres approach, and anastomosis was carried out (white arrow). Subsequent repeat stricture occurred 1 year later and was treated by refashioning of the anastomosis and subsequent transtubal balloon dilation with a satisfactory outcome. The patient was well and symptom free 2 years after operation.

The mucosal graft procedure of Smith (1964, 1969) is a procedure of historical interest only. This method was introduced for treating high strictures in which hilar dissection was thought to be impossible, and the proximal ducts could not be delivered for mucosa-to-mucosa anastomosis. The object of the procedure is to use a transhepatic tube to draw the jejunal mucosa high up into the hepatic ducts and allow apposition. The procedure was claimed to be easier and quicker, because no sutures were inserted. The transhepatic tube was left in place for 2 to 6 months, occasionally longer for difficult cases. Initially hailed as an important advance in technique (Kune & Sali, 1981), it is now clear that the dome of the jejunal mucosa drawn into the hepatic ducts may block significant secondary intrahepatic ducts, occluding and isolating segments of liver tissue (Blumgart, 1978; Blumgart et al, 1984). In addition, the mucosa may slip away postoperatively, and the jejunal loop may become detached (Fig. 42A.22). Recurrent stricture at the site of previous mucosal grafting is common (Blumgart & Kelley, 1984). This technique fell out of favor after several series of complex biliary strictures documented good to excellent long-term results using biliary-enteric anastomotic techniques without using the mucosal graft approach (Schol et al, 1995; McDonald et al, 1995; Chapman et al, 1995; Stewart & Way, 1995; Nealon & Urrutia, 1996; Tocchi et al, 1996; Lillemoe et al, 1997).

FIGURE 42A.22 Cholangiogram obtained by injection of a U-tube was used to develop a mucosal graft repair of a high bile duct stricture done 2 weeks before this radiograph was obtained. It was considered that there were no ducts visible at the hilus of the liver that would allow formal anastomosis. The mucosal graft is already widely separated from the biliary confluence (arrow). Repair was done by an approach to the left hepatic duct. A wide anastomosis was obtained easily, and the patient was well and symptom free with normal liver function tests 3.5 years after operation.

Combined Modality Approaches

The standard surgical techniques of biliary reconstruction described previously are suitable for most cases. In the most complex and difficult strictures, and especially in the presence of intrahepatic strictures and stones, even optimal surgical management is met with a disappointingly high incidence of postoperative intrahepatic stone formation, cholangitis, and recurrent stricture. Interventional radiologic and endoscopic techniques, used as primary therapy in this setting, are similarly unsuccessful because of recurrent cholangitis associated with stent occlusion or recurrent stricture after balloon dilation. Often, nonoperative techniques are technically impossible because of limited access.

Under such adverse circumstances, when the risk of recurrent stricture or stone formation is believed to be high, hepaticojejunostomy may be performed over a transjejunal tube brought to the exterior across the blind end of the Roux limb. The defunctionalized Roux limb is deliberately left long, and the end is secured subcutaneously or subperitoneally (Fig. 42A.23); this allows easy subsequent access for cholangiography, cholangioscopy, dilation, or stone removal. The blind end of the Roux limb may be reaccessed by percutaneous puncture under fluoroscopic guidance or via a small incision made under local anesthetic for late diagnostic or therapeutic procedures long after the transjejunal tube has been removed. In our experience, this approach is rarely necessary but can provide an improved chance of excellent outcome in difficult cases and may spare the patient the need for repeated major surgical intervention months or years later (Schweizer et al, 1991; McPherson et al, 1998). It is generally unnecessary to add the morbidity of a formal stoma, although such an approach has been reported (Barker & Winkler, 1984).

FIGURE 42A.23 Hepaticojejunostomy with a long, defunctionalized Roux limb with the end secured subcutaneously or subperitoneally to allow access for future diagnostic or therapeutic studies.

Portal Hypertension and Biliary Stricture

Patients with coexisting portal hypertension and biliary stricture are an especially difficult group to manage (see Chapter 70A, Chapter 70B ). This combination has been reported in 10% to 20% of patients at the time of referral (Blumgart & Kelley, 1984; Chapman et al, 1995). Portal hypertension may result from secondary biliary fibrosis or direct injury to the portal vein, or coincident hepatocellular disease may be evident from alcohol abuse, chronic hepatitis, or other causes. The presence of splenomegaly or a history of gastrointestinal bleeding in a patient with biliary stricture should prompt further investigation with esophagogastroduodenoscopy and angiography with delayed-phase splenoportography. Bleeding esophageal varices, particularly if accompanied by hypersplenism or ascites, render the overall prognosis far worse (Chapman et al, 1995; Way & Dunphy, 1972). Collateral venous channels in the subhepatic region and within adhesions make dissection difficult and bloody. Patients with portal hypertension often have a proximal stricture, and some have had multiple previous attempts at repair, further reducing the likelihood of a successful outcome.

In seriously ill patients with jaundice and portal hypertension, it is preferable to attempt nonoperative stenting or balloon dilation than to proceed to immediate definitive repair (Fig. 42A.24; Toufanian et al, 1978; Molnar & Stockum, 1978; Teplick et al, 1980; Schwarz et al, 1981; Pellegrini et al, 1984). In the face of severe gastrointestinal bleeding, initial measures must be directed at stopping the hemorrhage and resuscitating the patient (see Chapters 75A and 75B). If bleeding continues, consideration should be given to immediate splenorenal or transjugular intrahepatic portosystemic shunting (TIPS; see Chapter 76A, Chapter 76B, Chapter 76C, Chapter 76D, Chapter 76E ) to achieve control, with bile duct reconstruction deferred until a later date. Occasionally, successful biliary-enteric reconstruction can be done under these circumstances with no need to create an intraoperative vascular shunt (Perakath et al, 2003; Agarwal et al, 2008). The best and most convenient form of operative shunt is the splenorenal shunt (see Chapter 76C). TIPS has a limited patency, and such shunting is used most often as a bridge to transplantation. The risk of biliary injury and subsequent biliary-venous fistula is high in the setting of a dilated biliary tree and seems to be a major mechanism of early shunt failure (Jalan et al, 1996; Saxon et al, 1998). TIPS is unlikely to play a major role in the management of these patients; instead, percutaneous drainage or balloon dilation may be used along with the measures described earlier.

FIGURE 42A.24 A, Percutaneous transhepatic cholangiography showing a high (type 3) postcholecystectomy biliary stricture in a patient after cholecystectomy, during which there had been excision of the entire common hepatic duct. This was followed by two attempts at a mucosal graft repair and a left-sided hepaticojejunostomy by the Longmire-Sandford procedure. After failure of this operation, percutaneous intubation of the biliary ductal system was undertaken from the right side with attempted balloon dilation of the hepaticojejunostomy on three consecutive occasions. The radiograph shows the area of the hilus, marked by a surgical clip, and two strictures in the left hepatic ductal system, one just proximal to and the other at the hepaticojejunostomy (black arrows). A free endoprosthesis is seen (white arrow) lying in the jejunum. B, Cholangiogram obtained during attempted balloon dilation of the stricture reveals the passage of the catheter (black arrows) and the biliary system full of clot. The guidewire crosses the stricture, and a free endoprosthesis lies within the jejunal loop (white arrow). This procedure was followed by a severe episode of hemobilia requiring blood transfusion. C, Radiograph obtained during balloon dilation clearly shows the two strictures (arrows). D, Roux-en-Y hepaticojejunostomy was performed by the left hepatic duct approach, and a wide anastomosis was obtained (between the arrows). The previous hepaticojejunostomy to the left lobe was dismantled, and the new anastomosis was splinted by a tube passed through the left hepatic ductal system. The tube was removed 2 months later, and the patient was well and symptom free with normal liver function test results 2 years after operation.

If hemorrhage is encountered during stricture repair, hepaticostomy drainage may be performed as an initial measure, and a splenorenal shunt may be undertaken at a later date. Bile duct stricture repair done at the time of the shunting procedure can be extremely difficult and in any event is unwise at a time of severely compromised liver function. Occasionally, patients present with variceal hemorrhage after an otherwise successful stricture repair (Fig. 42A.25). In these instances, portosystemic shunting may be indicated as an emergency measure or, preferably, after initial conservative management. Injection sclerotherapy may control the bleeding successfully and obviate the need for operative intervention (see Chapter 75B).

FIGURE 42A.25 Splenoportography in a patient with benign bile duct stricture and a history of vascular injury at the initial operation. The patient presented with portal hypertension and bleeding esophageal varices. Only a portion of the right portal venous vasculature is outlined (black arrow). Note varices in the area of the gastric fundus (white arrow). Percutaneous transluminal cholangiography revealed a stenosis near the biliary confluence, but not a complete obstruction, and liver biopsy showed hepatic fibrosis. Biliary reconstruction was not undertaken; instead, the patient was managed with a splenorenal shunt and has remained well for several years, and repair of the stricture has never been necessary.