Minimally Invasive Choledochojejunostomy
Janak Parikh
C. Max Schmidt
Eugene P. Ceppa
DEFINITION
Hepaticojejunostomy is the operative formation of an anastomosis between the biliary tree and a Roux limb of the jejunum to manage biliary obstruction secondary to benign or malignant strictures, or to reconstruct continuity following resection of the extrahepatic biliary tree or pancreaticoduodenectomy.
DIFFERENTIAL DIAGNOSIS
Benign
Traumatic or iatrogenic bile duct injury
Chronic pancreatitis
Choledochal cyst
Mirizzi’s syndrome
Malignant
Extrahepatic cholangiocarcinoma (palliative or after resection)
Periampullary tumors (palliative or after resection)
Portal lymphadenopathy (palliative)
PATIENT HISTORY AND PHYSICAL FINDINGS
History—The following features may be obtained:
Weight loss (malignancy vs. malabsorption)
Fevers/chills (cholangitis)
Yellow eyes/skin (obstructive jaundice)
Tea-colored urine (obstructive jaundice)
Acholic stools (obstructive jaundice)
Right upper quadrant pain (distended gallbladder, may suggest a process distal to the cystic duct confluence)
Physical examination
Temporal wasting (cachexia)
Scleral icterus
Jaundiced skin
Right upper quadrant tenderness
Courvoisier’s sign—painless, palpable gallbladder with jaundice
IMAGING AND OTHER DIAGNOSTIC STUDIES
Ultrasonography—preferred initial evaluations as it is readily available and inexpensive. Findings may include the following:
Gallbladder
Stones
Cholecystitis
Biliary tree
Extrahepatic duct dilatation
Intrahepatic duct dilatation
Cross-sectional imaging
Computed tomography abdomen/pelvis (CT A/P) with intravenous (IV) contrast—Triple-phase CT A/P is warranted in most cases of obstructive jaundice as part of determining the probable etiology and defining surgical anatomy. This includes the following:
Determine location of hepatic arteries and potential anomalous anatomy
Compression, invasion, or thrombosis of portal, splenic, and/or superior mesenteric veins
Magnetic resonance imaging/magnetic resonance cholangiopancreatography (MRI/MRCP) with IV contrast is preferred by some institutions. It is superior to ultrasound (US) and CT in identifying the location of biliary strictures.
Cholangiography
Endoscopic retrograde cholangiopancreatography (ERCP) is the “gold standard” when biopsy or other therapeutic intent is warranted.
Provides superior diagnostic information by identifying level of obstruction/anatomy
Allows for sampling of tissues at the level of obstruction via brushings for cytology
Is therapeutic by placement of biliary endoprosthesis to decompress biliary tree
Percutaneous transhepatic cholangiography (PTC) is reserved for therapeutic intervention when ERCP is technically not feasible, that is, following gastric bypass or in the clinical setting of concomitant gastric outlet obstruction.
Second option—Palliation is less effective as the patient will have pain from the PTC site and will need to perform daily care to the catheter.
SURGICAL MANAGEMENT
Preoperative Planning
Underlying cardiopulmonary disease must be evaluated when considering the laparoscopic approach; affected patients may not tolerate reduced venous return or clear increased concentrations of carbon dioxide resultant from the pneumoperitoneum.
An extensive past abdominal surgical history or previous peritonitis may impact the ability to perform the hepaticojejunostomy laparoscopically due to extensive adhesions. Prior abdominal surgery may also impact the approach of initial peritoneal access and subsequent port placement (i.e., avoiding abdominal wall defects), or mandate modification of the formation or routing of the reconstructive Roux limb.
Morbid obesity can preclude adequate laparoscopic visualization, but these patients have the greatest potential benefit of a minimally invasive approach due to the reduced wound morbidity. Obesity mandates several considerations:
Distinct, longer instrumentation may be required to reach the right upper quadrant and level mechanics, thus may impact fine motor movements limitations with suturing and intracorporeal knot tying.
Mobilization of the hepatic flexure and a Kocher maneuver are made more difficult when the transverse mesocolon
and omentum contain more fat and organs are larger in size overall.
Large, friable livers as a result of fatty liver disease and are prone to lacerations (hemorrhage within the operative field significantly impairs image brightness).
Positioning
The patient is positioned supine with both arms abducted on arm board extensions of the operating table.
A nasogastric tube and Foley catheter are placed.
Use a footboard.
TECHNIQUES
LAPAROSCOPIC CHOLEDOCHOJEJUNOSTOMY
Port placement and role of each in the procedure is depicted in FIG 1.
To first create the Roux limb, elevate and retract the omentum and transverse colon to the upper abdomen. The ligament of Treitz is identified at the base of the transverse mesocolon. Reverse Trendelenburg positioning may facilitate visualization by dropping the small bowel into the lower abdomen.
A point for division of the proximal jejunum is identified distal enough from the ligament of Treitz to facilitate the jejunojejunostomy and such that the mesentery will have adequate length to reach the right upper quadrant without tension on the blood supply. At this location, the small bowel is divided using a laparoscopic stapler with a 2.5-mm staple load after a window is created between the vasa rectae of the small bowel.
Use bipolar energy device or a vascular staple load to divide the mesentery toward the base. Use care not to encroach on the arterial arcade on either side of the divided bowel. This maneuver will give additional length of the mesentery necessary to reach the bile duct without putting the anastomosis under undue tension. The bowel proximal to the staple line is the alimentary limb; an additional 40 to 60 cm of small bowel distal to the staple line is measured and referred to as the Roux limb.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
