Chandrajit P.Raut, Jean-Nicolas Vauthey
True mid bile duct tumors are very rare. Most patients with mid bile duct obstruction should be considered to have gallbladder cancer until proven otherwise. Mid bile duct resections are usually performed for the rare mid duct cholangiocarcinomas or for patients with early gallbladder cancer and tumor at the cystic duct margin.
Indications and Contraindications
Diagnosis of biliary strictures without confirmed malignancy Diagnosis of suspected benign disease
Contraindications ■ Malignant disease involving biliary confluence (hilar cholangiocarcinoma)
■ Vascular invasion involving the main trunk of the portal vein or the proper hepatic artery
■ Bilateral vascular involvement of hepatic arterial and/or portal venous branches
Preoperative Investigation and Preparation for the Procedure
CT scan, CT angiography or MRI:
Alcohol intake, cholelithiasis, choledocholithiasis, primary sclerosing cholangitis/ulcerative colitis, choledochal cysts, Caroli's disease, recurrent pyogenic cholangiohepatitis, biliary parasites, exposure to chemical carcinogens Jaundice (90-98 % of patients), weight loss (51%), abdominal pain (45%), fever (20%)
Alkaline phosphatase, g-glutamyl transpeptidase, ALT,AST, coagulation parameters
Assess intra- and extrahepatic biliary obstruction, presence of gallstones, tumor extension, vascular involvement
Identify metastases, define relationship between tumor mass
(if detectable) and liver, assess lobar atrophy or compensatory hypertrophy, hepatic arterial anatomy
Delineate proximal extent of tumor, number of tumors
(10% of cases will have multiple tumors)
Percutaneous catheter drainage (positive in 47% of cases), fine needle aspiration (sensitivity 77%), endoscopic transpapillary biopsy, ERCP brushing
The abdomen is explored through a bilateral subcostal incision. Retraction is maintained with broad blade retractors from a fixed support, elevating the costal margin. A soft retractor blade (malleable) may be inserted from above to retract segment 4. The ligamentum teres is divided, and the falciform ligament is separated from the anterior abdominal wall. Cephalad traction on the ligamentum teres provides additional exposure of the undersurface of the liver. If present, the bridge of liver parenchyma between segment 4 and the left lateral bisegment is divided with electrocautery; bleeding is easily controlled as this tissue rarely contains large vessels. This maneuver exposes the umbilical fissure for a later step.
STEP 2 Division of the distal CBD
The gallbladder, if present, is dissected free from its liver bed. The proximal CBD and the right and left hepatic ducts are dilated proximal to the stricture, unless stenting across the stricture has drained the obstruction. The distal CBD is isolated and divided early in the dissection above the superior edge of the pancreas and a frozen section analysis of the margin is obtained. The distal CBD stump is ligated in a figure-of-eight fashion with 4-0 PDS suture on an SH needle.
STEP 3 Division of the proximal CBD
The CBD, gallbladder and hepatoduodenal lymph nodes are reflected superiorly en bloc, exposing the hilar vessels and confirming resectability. Dissection is continued between the tumor anteriorly and the hepatic artery posteriorly. The hilar plate is lowered by dividing the peritoneal reflection at the base of segment 4 and the umbilical fissure is opened to expose the extrahepatic left bile duct (A). As this exposure is extended to the left, a branch of the portal vein or hepatic artery to segment 4 may be encountered and should be preserved. This exposure allows the base of segment 4 to be elevated; the malleable blade retracting the quadrate lobe may be repositioned. The proximal duct is transected at the confluence of the right and left hepatic ducts, and the specimen is marked for orientation. Additional duct margins are submitted for intraoperative microscopic frozen section examination. The opening in the proximal duct at the site of transection can be extended into the extrahepatic left bile duct sharply using Pott's scissors (B).
If the proximal bile duct is dilated, there may be no need to lower the hilar plate or extend the incision to the left hepatic duct - Y.F.
The biliary-enteric continuity is restored with a side-to-side retrocolic Roux-en-Y hepaticojejunostomy with a single layer of interrupted, absorbable sutures (5-0 PDS vs. an shRVI needle as preferred by the authors). This technique incorporates the extrahep-atic portion of the left duct in the anastomosis, as first described by Hepp and Couinaud, thus creating a wide side-to-side hepaticojejunostomy. A 70-cm jejunal Roux-en-Y limb is prepared and brought through the transverse mesocolon to the right of the middle colic artery; the stapled end does not need to be oversewn. Both the left duct and the jejunum are incised longitudinally for a 2-cm-wide anastomosis. The anterior row of No. 5-0 absorbable sutures is brought through the bile duct wall and the needles are left intact (A). A Gabbay-Fisher suture guide (Genzyme Co., Fall River, MA) facilitates the management of these free sutures by organizing them; each guide holds up to 16 sutures. Gentle retraction on these sutures superiorly allows exposure of the posterior edge of the ductal incision. Precise mucosa-to-mucosa anastomosis is established with interrupted No. 5-0 absorbable sutures between the posterior edge of the ductal incision and the posterior edge of the jejunal incision. The posterior sutures are tied with the knots on the inside (B). The anterior stay sutures are then placed through the jejunum to complete the anterior row of sutures. These are tied such that the knots are exterior (C). Internal stenting is not required. A drain on bulb suction is left near the anastomosis and brought through the abdominal wall in the right upper quadrant.
Local Postoperative Complications
- Bile leak
- Cholangitis (rare)
■ Preoperative biliary drainage with a transtumoral catheter may be of technical assistance for the hilar dissection and biliary enteric anastomosis, but does not reduce perioperative morbidity or duration of hospitalization. Drainage is only indicated in patients with sepsis and cholangitis.
■ If present, the bridge of liver parenchyma between segment 4 and the left lateral bisegment is divided by electrocautery.
■ Duct margins should be submitted for intraoperative frozen section analysis.
■ A Gabbay-Fisher suture guide facilitates the management of these free sutures by organizing them to minimize entanglement; each guide holds up to 16 sutures.
■ Internal stenting is not required.
■ Resection and reconstruction utilizing the Hepp-Couinaud approach, which employs a wide mucosa-to-mucosa anastomosis extended to the left hepatic duct, has the advantage over an end-to-side anastomosis of having a lower rate of stricturing.
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