Choledochojejunostomy Technique

A right subcostal, upper midline, right paramedian, or bilateral subcostal “bucket-handle” ^[1] incision may be used. The last of these is preferred in patients with unfavorable body habitus, particularly when exposure remains poor after a right subcostal approach is attempted. ^[7] A self-retaining retractor is placed if needed.

Creation of the biliary-enteric anastomosis itself involves the following three main steps ^[8] :

• Exposure
• Dissection
• Establishment of biliary continuity

Depending on the underlying pathology, lysis of adhesions may be mandatory upon entry into the abdomen and dissection toward the area of the hepatoduodenal ligament. Blunt dissection is used to free the edge and undersurface of the liver. After the peritoneal attachments lateral to the duodenum are divided, the Kocher maneuver is performed to mobilize the duodenum medially, further exposing the foramen of Winslow and the portal triad. ^[9]

After careful dissection of the plane between the underside of the the right hemiliver and the duodenum, the portal triad comes into view. Although in the majority of people, the hepatic artery lies to the left of the common bile duct (CBD), there are numerous potential anatomic variations in this area that must be kept in mind. Most notably, a replaced right hepatic artery (see the image below) may arise from the superior mesenteric artery and course to the right of the portal vein, the common hepatic duct (CHD), and the CBD.

In some instances, aspiration with a 25-gauge needle may help identify the CBD. ^[1]

Once isolated, the CBD is encircled and transected above the level of obstruction. The distal CBD is then doubly ligated. Bile cultures are taken at this time, and if appropriate, the duct is irrigated or explored for stone or debris. The proximal end is then inspected and trimmed to healthy, even edges as needed.

The CHD and CBD receive their blood supply from axial arteries just lateral and medial to the duct (see the image below). These arteries originate from the intrahepatic arterial collaterals feeding the biliary tree superiorly and from the gastroduodenal artery inferiorly. With this in mind, skeletonization of the CBD should be avoided because it can compromise the blood supply and lead to ischemic stricturing.

The ligament of Treitz is then identified, and a proximal loop of jejunum that comfortably reaches the subhepatic space is identified. After the jejunal arcades are assessed for adequacy of blood supply, this loop is transected with a gastrointestinal anastomosis (GIA) stapler. Alternatively, if the jejunum is divided between bowel clamps, the distal end is closed with two layers of interrupted silk suture. ^[9]

The distal jejunum is rotated through the avascular space just to the right of the middle colic artery up into the porta hepatis. The proximal (afferent) divided end of the jejunum is then sutured to the distal end of the jejunum 45 cm aborally from the divided end where the choledochojejunostomy will be created. After the choledochojejunostomy is complete, the defect in the transverse mesocolon is closed, and several interrupted absorbable sutures are used to anchor the afferent limb to the mesocolon. ^[1]

In the case of a very dilated CBD, the choledochojejunostomy may be performed in an end-to-end fashion (see the image below).

The author prefers a single-layer closure with 3-0 absorbable suture. Two stay sutures are placed at the corners, dividing the anterior and posterior halves. The posterior wall of the anastomosis is fashioned first, starting with a single suture placed midway and followed by a meticulously placed row of interrupted sutures, each with the knot tied intraluminally and the suture held on slight tension to assist in placement of the subsequent stitch.

Starting at each corner, alternating interrupted sutures are then placed and tied to approximate the anterior wall of the anastomosis. These sutures are placed in an inside-outside-outside-inside fashion so that the knot lies within the lumen. The final few stitches at the center of the anterior wall of the anastomosis are tied on the outside. The most important principle in fashioning this anastomosis is taking full-thickness bites of the duct and the jejunum with the placement of each suture. ^[1]

More commonly, given the size mismatch between the CBD and the jejunum, an end-to-side mucosa-to-mucosa choledochojejunostomy is performed. The stump of the jejunal limb, previously divided by a GIA stapler, is oversewn with a layer of interrupted absorbable sutures. An electrocautery device is then used to the divide the jejunum longitudinally on the antimesenteric border approximately 5 cm distal to this closure. The size of this jejunostomy is determined by the size of the transected end of the CBD. The anastomosis is then carried out in a single layer, mucosa to mucosa, using the Blumgart technique. ^[1]

Interrupted absorbable monofilament 4-0 or 5-0 sutures are placed on the anterior wall of the proximal bile duct inside out and clamped with rubber shods. Lifting of this row of sutures then increases the visibility for placement of the posterior-layer sutures in a similar fashion. These are placed through the full thickness of the tissue in an inside-out-outside-in manner from bile duct to jejunum and tied, with knots woven intraluminally so as to afford exact mucosal apposition.

The anterior wall is then completed by using the needles previously passed through the bile duct wall. Starting at each corner, the needle is passed from outside in, tied, and cut, again with the knot facing the lumen. The final few stitches at the center of the anterior wall are placed so that the knot lies on the outside. The key to a successful choledochojejunostomy is creating a tension-free anastomosis with direct mucosa-to-mucosa apposition at this stage. A few anchoring stitches may be placed between the jejunum and surrounding structures of the hepatoduodenal ligament.

If internal stenting is desired, it is placed through a separate opening in the bile duct or in a retrograde manner through an opening in the duodenum (see the image below).

The stent is then brought out through the abdominal wall at the conclusion of the operation. An alternate maneuver is to pass a Silastic tube with multiple holes through the liver parenchyma, into the biliary tree, and across the anastomosis before completion. The decision to leave an internal stent varies with physician preference. The author finds stenting most successful when used for management of biliary reconstructions after iatrogenic bile duct injury.

Intraoperative/postoperative bleeding

Careful attention must be paid to identifying the arteries related to the biliary system at the time of initial dissection. The surgeon's familiarity with biliary anatomy and the most common aberrations is crucial. If the arteries to the bile duct are not identified early and preserved, intraoperative bleeding may further obscure a challenging operative field, making it difficult to identify key structures and avoid inadvertent injury. If injury to these arteries is not identified early, postoperative anastomotic bleeding may also occur.

Less common, but equally consequential, are iatrogenic portal vein injuries, hepatic artery injuries, and right hepatic artery ligation. These injuries can be prevented by performing meticulous dissection early during exposure to ensure that all major vessels are properly identified before any transection.

Stricture

Injury to the arteries feeding the bile duct, caused either by direct division or by heat injury from extensive electrocautery use, can lead to duct ischemia. Such an injury could manifest early as a bile leak or late as a bile duct or anastomotic stricture. ^[10] Younger patients may be at higher risk for postoperative stricture. ^[11]

Sano et al retrospectively assessed long-term outcomes after therapeutic ERCP using balloon-assisted enteroscopy (BAE) to manage anastomotic stenosis in choledochojejunostomy or pancreaticojejunostomy. ^[12] ​ They found the outcomes of BAE-ERCP to be comparable to those of percutaneous transhepatic treatment or surgical reanastomosis.

Biliary drainage tube dislodgment

Care should be taken to allow enough laxity of the T-tube intra-abdominally and to anchor the tube to the skin adequately so as to prevent inadvertent dislodgment of the tube, which, in addition to causing a bile leak or enterostomy, may cause a narrowing of the anastomosis in cases where stenting was performed across a narrow or difficult anastomosis.

Anastomotic leakage

Leaks of the anastomosis present most commonly as bilomas or peritonitis from a noncontained leak of bile or enteric content. The key to prevention of this complication is performing a tension-free anastomosis. This is achieved by preparing a long enough jejunal loop that is well vascularized, passed in a retrocolic fashion, and anchored to surrounding tissue after anastomosis. Attention to direct mucosa-mucosa apposition during anastomosis will also improve healing and help prevent postoperative leakage.

Significant risk factors for postoperative anastomotic leakage include biliary reconstruction following injury and a high anastomosis (above the confluence). ^[11]

Distal common bile duct stump leak

Failure to ligate the distal CBD stump or poor ligature placement may lead to leakage of enteric contents from the duodenum. This complication can be severe, leading to peritonitis or abscess and the need for reexploration. Leakage of gastric content in this area also threatens the anastomosis.

This complication can be avoided by carefully dissecting and ligating the distal CBD. Intimate knowledge of aberrant ductal anatomy, such as an accessory bile duct running in parallel to the CBD, may decrease the incidence of stump leaks.

Reflux cholangitis

Reflux cholangitis may occur after choledochojejunostomy. Treatment by stenting has been described. ^[13]