In some cases, especially those in which there have been repeated bouts of cholangitis and the liver has become swollen and fibrotic, a condition most frequently seen after failed hepaticojejunostomy, segment 4 may overhang the upper bile ducts. In these cases resection or coring of segment 4 is also a useful adjunct. Resection provides excellent access to the upper part of the porta hepatis without relying on forceful retraction on the liver and provides room for the bowel to rest when the hepaticojejunostomy is performed. This maneuver is not restricted only to operations in which a portion of the right biliary tree has been isolated. It is also useful for types E3 and some E2 injuries. Bile ducts with stents may be seen at the bottom of the picture.
Close-up of bile ducts. Type E4 injury in which the right bile ducts have been exposed by dividing the gallbladder plate as described and segment 4 has been partially resected. Preoperatively placed stents are emanating from the ducts, and the ducts have been incised on their anterior surfaces for 1.5 cm. Sutures have been placed in the anterior row of the proposed anastomosis along with a few in the posterior row (A).
In figure B it was chosen to do a "cloacal" anastomosis rather than a double-barreled anastomosis because the ducts were close and the intervening scar small. Although the center of the anastomosis may scar, the long lateral horns are mucosa to mucosa and effectively a double-barreled anastomosis results.
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