In types E4 and E5 and B and C injuries the Hepp-Couinaud approach alone will not suffice, as there is an isolated portion of the biliary tree on the right side. The key to dissection is based on the fact that the main right and left bile ducts lie in the same coronal plane, invested in fibrous Wallerian sheaths. Also of importance is that the gallbladder plate, a layer of fibrous tissue on which the gallbladder normally rests, attaches to the anterior surface of the sheath of the main right portal pedicle. To find the bile duct within the sheath of the pedicle the cystic plate must be detached from the anterior surface of the sheath of the right portal pedicle.
The liver capsule is divided toward the right until the cystic plate is met where it attaches to the sheath of the right portal pedicle. It is a stout ribbon of fibrous tissue about 2 mm in thickness and 5-8mm in breadth.
After dividing the cystic plate the liver lifts off the right portal pedicle. The division of the liver capsule is carried about 1 cm beyond the cystic plate. Now the liver (segment 5) may be dissected off the portal pedicle, by lifting and coring the base of segment 5. This exposes the anterior surface of the sheath of the right portal pedicle. The position of the right duct(s) in the pedicle is evident from the position of the stent (not shown). To prepare the right bile duct for anastomosis it is opened on the anterior surface (inset). Ideally, the duct(s) is opened 1 cm. The entire anastomosis is then performed to the anterior surface of the duct as described above for the left duct. When performing two (or more) anastomoses the anterior row in the bile ducts should be placed first and then the posterior row placed and tied, completing all anastomoses together by placement of the anterior row sutures in the bowel and tying of all anterior row sutures.
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