Injuries at the hepatic duct confluence present the surgeon with a technically demanding repair, often combined with life-threatening sequelae such as sepsis and portal hypertension. Moreover, the possibility of litigation is ever present, even for those not responsible for the initial injury. In this review, we discuss the approach to patients with proximal bile duct injuries, with emphasis on preoperative evaluation and the technical aspects of biliary reconstruction.
A, Percutaneous transhepatic cholangiogram showing a surgical clip (arrow) occluding the common hepatic duct just below the confluence. B, Coronal single-shot fast spin-echo magnetic resonance cholangiopancreatography section showing a surgical clip (arrow) occluding the common hepatic duct just below the confluence. (Reprinted with permission from Radiology.19 Copyright 1998, Radiological Society of North America.) C, Coronal single-shot fast spin-echo magnetic resonance cholangiopancreatography section in a patient with recurrent cholangitis after multiple attempts to repair a postcholecystectomy bile duct injury. The hepatic duct confluence (white arrow) is shown. There is also excess fluid 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 that had been excluded from the anastomosis. (Reprinted with permission from Radiology.19 Copyright 1998, Radiological Society of North America.)
Cross-sectional T1-weighted magnetic resonance image showing an atrophic left hepatic lobe (black arrow) with dilated and crowded intrahepatic ducts (white arrow).
Right lobe atrophy and compensatory left lobe hypertrophy. A, The normal relationship of the porta hepatis structures is shown. B, With right lobe atrophy and left lobe hypertrophy, the porta hepatis structures are rotated posteriorly and to the right. The portal vein comes to lie more anteriorly with respect to the bile duct, which is rotated posterolaterally. (Reprinted with permission from Surg Clin North Am.22 Copyright 1994, WB Saunders Co.)
Roux-en-Y hepaticojejunostomy with an extended access loop. The blind end is anchored in the subcutaneous tissues of the abdominal wall. The anastomosis is splinted with a transjejunal tube. The tube track provides access for the interventional radiologist. Selected patients likely to require further manipulations may benefit from this approach. (Reprinted with permission from Surgery of the Liver and Biliary Tract.23 Copyright 1994, Churchill-Livingstone.)
A, Schematic sagittal section showing the relationship of segment IV (quadrate lobe [Q]) to the left hepatic duct (A). The caudate lobe (CL, segment I), left portal vein (B), and left hepatic artery (C) are also shown. The left portal triad is encased in a reflection of the lesser omentum, which fuses with the Glisson capsule at the base of the quadrate lobe. The point of incision to lower the hilar plate is indicated by the arrow. (Reprinted with permission from Surgery of the Liver and Biliary Tract.23 Copyright 1994, Churchill-Livingstone.) B, Exploded view of the liver showing its segmental anatomy. The left hepatic duct always pursues an extrahepatic course at the base of the quadrate lobe (segment IV), within the groove separating it from the caudate lobe (segment I; see Figure 7). The ligamentum teres marks the umbilical fissure. The extrahepatic portion of the right hepatic duct is more variable and shorter than the extrahepatic portion of the left hepatic duct. (Reprinted with permission from Surg Clin North Am.22 Copyright 1994, WB Saunders Co.)
Opening the umbilical fissure requires dividing the bridge of liver tissue that often connects segments III and IV, which may be substantial in some patients. This can be done easily by passing a curved director and dividing the tissue with electrocautery, taking care to avoid injuring the underlying left portal triad. Dissection is facilitated by firm upward traction on the ligamentum teres, which exposes the undersurface of the liver. (Reprinted with permission from Surgery of the Liver and Biliary Tract.23 Copyright 1994, Churchill-Livingstone.)
The hilar plate has been lowered and the left hepatic duct identified at the base of the quadrate lobe (segment IV). The right and left hepatic ducts may be further exposed with dissection toward the patient's right and the umbilical fissure, respectively. If necessary, the right portal pedicle can be further exposed by splitting the hepatic parenchyma in the plane of the gallbladder fossa (dashed line). A Roux-en-Y loop of jejunum has been prepared and brought through the transverse mesocolon. (Reprinted with permission from Surg Clin North Am.22 Copyright 1994, WB Saunders Co.)
A, The initial step in creating a Roux-en-Y hepaticojejunostomy. The anterior row of sutures on the bile duct is placed first. Working from left to right, the sutures are passed from inside out and secured on a clamp with the needles left in place. B, The anterior sutures are elevated to display the posterior duct wall. The posterior sutures are now placed, from jejunum to bile duct, again working from left to right. None of the sutures is tied but rather secured with a clamp until the entire row is completed. This allows unhindered access to the back wall of the bile duct and precise placement of each stitch. Inset, If multiple separate anastomoses must be performed, the entire anterior row of sutures is placed first to all exposed ducts followed by the posterior row. This allows the separated duct orifices to be treated as if single. (Reprinted with permission from Surg Clin North Am.22 Copyright 1994, WB Saunders Co.)
The anterior and posterior row of sutures are in place and held taut. The jejunum is slid upward along the posterior sutures until its back wall is flush with the back wall of the duct. The posterior sutures are tied and cut, leaving the corner sutures clamped. (Reprinted with permission from Surgery of the Liver and Biliary Tract.23 Copyright 1994, Churchill-Livingstone.)
With the posterior row secured, the anterior row is completed. Working from right to left, the needles of the previously placed anterior row are serially passed outside inward through the anterior jejunal wall. The sutures are not tied until all have been placed. (Reprinted with permission from Surgery of the Liver and Biliary Tract.23 Copyright 1994, Churchill-Livingstone.)
A, The anterior row of sutures has been placed and each is then tied, working from left to right. B, The completed anastomosis with all knots inside for better mucosal apposition. (Reprinted with permission from Surgery of the Liver and Biliary Tract.23 Copyright 1994, Churchill-Livingstone.)
Thank you for submitting a comment on this article. It will be reviewed by JAMA Surgery editors. You will be notified when your comment has been published. Comments should not exceed 500 words of text and 10 references.
Do not submit personal medical questions or information that could identify a specific patient, questions about a particular case, or general inquiries to an author. Only content that has not been published, posted, or submitted elsewhere should be submitted. By submitting this Comment, you and any coauthors transfer copyright to the journal if your Comment is posted.
* = Required Field
Disclosure of Any Conflicts of Interest*
Indicate all relevant conflicts of interest of each author below, including all relevant financial interests, activities, and relationships within the past 3 years including, but not limited to, employment, affiliation, grants or funding, consultancies, honoraria or payment, speakers’ bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. If all authors have none, check "No potential conflicts or relevant financial interests" in the box below. Please also indicate any funding received in support of this work. The information will be posted with your response.
Some tools below are only available to our subscribers or users with an online account.
Download citation file:
Web of Science® Times Cited: 26
Customize your page view by dragging & repositioning the boxes below.
More Listings atJAMACareerCenter.com >
Enter your username and email address. We'll send you a link to reset your password.
Enter your username and email address. We'll send instructions on how to reset your password to the email address we have on record.
Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.