Resection and Reconstruction of the Biliary Tract

Chapter 39 Resection and Reconstruction of the Biliary Tract



David A. Bruno, MD, Thomas M. Fishbein, MD



INTRODUCTION


In 1891, in Dresden, Germany, Oskar Sprengel published the first report of a choledochoenterostomy. In this patient, after a successful cholecystectomy, Dr. Sprengel was unable to clear the distal common bile duct of stones. A choledochotomy was made, and the common bile duct was anastomosed to the duodenum. Although the first patient survived, subsequent attempts resulted in several deaths, presumably from bile peritonitis followed by sepsis.1,2 Not until a successful series of cases in the early 20th century was the operation accepted as standard of care.3 Many years later, it was recognized that hepatic ducts could also be resected and reconstructed with attention to two simple principles: The anastomosis must be performed free of tension and with direct mucosal apposition to facilitate proper healing. These principles still maintain today.


Safe and effective biliary reconstruction requires intimate knowledge of normal anatomy as well as commonly recognized variations in biliary and vascular anatomy of the liver and porta hepatis. Proper exposure allowing careful dissection in this region is of paramount importance. Resection and reconstruction, performed to establish biliary continuity with the small bowel, is the usual goal, regardless of the specific pathology. When malignancy is the indication for surgery, anatomic planes are frequently altered owing to inflammation, desmoplastic reaction, and sometimes, tumor mass, increasing the complexity of the procedure. All procedures involving the biliary tract involve several operative steps: exposure, dissection, and establishment of biliary continuity.



INDICATIONS



• Bile duct obstruction

• Biliary injury—trauma

• Biliary fistula


OPERATIVE STEPS



Step 1 Incision

Step 2 Exposure of hepatoduodenal ligament

Step 3 Dissection of common bile duct

Step 4 Duct division

Step 5 Duct resection or closure

Step 6 Reestablishment of biliary continuity


OPERATIVE PROCEDURE


Resection and restoration of biliary continuity above or below the hepatic bifurcation.



Operative Incision


This is reviewed in Section IV, Chapter 32, Right Hepatectomy.


Briefly, this can be optimally accomplished through a right subcostal incision, a midline incision, or a bilateral subcostal incision. Prior operations may dictate which of these is chosen, whereas in patients with no prior operations, a right or bilateral subcostal incision is preferred.



Bile Duct Isolation



Extrahepatic Bile Duct—Blood Supply


The blood supply to the extrahepatic bile duct is derived from vessels on the medial and lateral walls of the duct, sometimes referred to as “9 o’clock and 3 o’clock position”4 (Fig. 39-1). Blood flow derives both from intrahepatic arteriobiliary collateral circulation downward and upward from the gastroduodenal artery.


image

Figure 39-1 Bile duct lateral vessels. Note the right hepatic artery courses posterior to the common bile duct.



Bleeding from Peribiliary Vessels



• Consequence



Failure to avoid or ligate these vessels and adequately control hemorrhage can lead to three possible complications. First, poor visualization may increase the likelihood of injury to other vital structures, most commonly, the right hepatic artery. Second, postoperative bleeding from the anastomosis may occur. Third, injury and extensive coagulation may lead to ischemia of the duct, leading to late stricture formation at the anastomosis.

Grade 3 complication


• Repair



Careful ligation of larger peribiliary vessels at the point of transaction of the duct should be undertaken, usually with fine monofilament suture. Smaller vessels may be controlled with electrocautery. Care must be taken when using electrocautery because thermal damage to the biliary tree may result in late stricture.5


• Prevention



Preoperative understanding of the normal and variant anatomy of the biliary tree and its surrounding vessels is essential. In normal anatomy, the common bile duct is derived from one left and one right hepatic duct joining at the hepatic hilum. The right hepatic artery branches from the proper hepatic artery medial to the duct, giving off small branches to the bile duct. Additional branches may be derived from the right hepatic artery lateral in the porta hepatis once it has passed posterior to the duct. The right hepatic artery bifurcates into anterior and posterior sectoral branches lateral to the duct. A replaced right hepatic artery sometimes courses lateral to the portal vein and gives off branches to the bile duct.


Common Hepatic Artery Injury



• Consequence



Hepatic artery anatomy can sometimes be obscured by pathology and variations in anatomy.6–12 As the duct is dissected and prepared for division or resection, identification of the common hepatic artery origin should be noted. Inadvertent injury to the hepatic artery will result in brisk hemorrhage. Complete ligation and division may result in ischemia of the right hepatic lobe of the liver. This can result in hepatic parenchymal damage postoperatively, sometimes leading to intrahepatic biliary necrosis, biloma formation, or abscess.

Grade 3 complication


• Repair



Incomplete transection of the proper hepatic artery should immediately be recognized. Control of the proximal and distal segments with vascular clamps should immediately be obtained. The artery itself should be repaired with an appropriately sized monofilament suture. Repair should be made in a transverse fashion in order to avoid narrowing of the artery. If the artery has suffered injury that makes a clean complete primary repair impossible, the authors recommend completing transection of the artery at the site of the injury and direct end-to-end anastomosis.13,14


• Prevention



Never transect the common bile duct until the hepatic artery has been positively identified at the level of planned transection. Encircle only the bile duct if possible.


Proper Hepatic Artery Injury



• Consequence



Variations in both the right and the left hepatic arteries are common.15 Division of the proximal common bile duct without identification of arterial supply in the porta should be avoided (Fig. 39-2). Early proper hepatic arterial injury can lead to hemorrhage and hepatic parenchymal ischemia. Unrecognized division of these arteries has been associated with strictures and the formation of bilomas late after surgery.16–18

Grade 4 complication

image

Figure 39-2 Replaced right hepatic artery. This usually runs posterior to the portal vein, but may then course anteriorly to lie just behind the bile duct above the cystic duct.



• Repair



Inadvertent transection of the right or left hepatic artery should be repaired with an end-to-end anastomosis after proximal and distal control is established.19–22 Nonabsorbable monofilament sutures are appropriate for repair. In the patient in whom an accessory hepatic artery branch exists and either it or the proper branch is injured, an injury of one may not require repair. The proximal stump of the injured vessel may be examined for backbleeding, which if it is judged to be pulsatile and sufficient, implies adequate intraparenchymal collateral circulation. Such an accessory branch may be ligated. High injuries of right hepatic artery branches may not allow distal control, thus requiring direct suture repair or closure.


• Prevention



Proper hepatic artery injury prevention begins with an intimate knowledge of variations before entering the operating room. Potentially hazardous variations of hepatic artery anatomy include an early trifurcation branching into (1) right and (2) left hepatic artery branches and the (3) gastroduodenal artery low in the porta hepatis, the right hepatic artery deriving from the superior mesenteric artery posterior to the portal vein, the right hepatic artery passing anterior to the common bile duct, and the entire proper hepatic artery arising from the gastroduodenal artery (Fig. 39-3).4 Early identification of the proper hepatic artery by palpation medial to the bile duct low in the porta hepatis is advantageous.

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Jun 21, 2017 | Posted by in GENERAL SURGERY | Comments Off on Resection and Reconstruction of the Biliary Tract

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