Laparoscopic Biliary Bypass
Laparoscopic cholecystojejunostomy is a simple procedure that is described in this chapter. Other, more complex forms of biliary diversion have also been performed laparoscopically and are referenced at the end.
Steps in Procedure
Obtain laparoscopic access and explore abdomen
Decompress Gallbladder with Needle (Bile Should be Golden, not White)
If necessary, perform cholangiogram through gallbladder to confirm cystic duct patency
Enlarge puncture site to accommodate stapler
Identify loop of jejunum that reaches comfortably to gallbladder
Place stay sutures to approximate the jejunum and gallbladder
Create opening in jejunum
Place endoscopic linear stapler into enterotomies and fire
Inspect staple line for hemostasis
Close enterotomy
Close trocar sites greater than 5 mm
Hallmark Anatomic Complications
Failure to decompress (cystic duct loses patency)
List of Structures
Liver
Bile duct
Gallbladder
Cystic duct
Trocar Placement and Decompression of Gallbladder (Fig. 66.1)
Technical and Anatomic Points
Set up the room as for a laparoscopic cholecystectomy. Introduce the laparoscope through an infraumbilical portal and explore the abdomen. Cholecystojejunostomy will provide adequate decompression of the obstructed common duct only if the cystic duct is patent. If this is true, the gallbladder will appear tensely distended. Place secondary trocars as shown in Fig. 66.1A. The right lower quadrant trocar site will be used for a laparoscopic linear stapling device; current devices require a 12-mm port. The other two ports should accommodate graspers and needle holders. For most situations, two 5-mm ports will suffice.
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