STEP 5Repair of the distal common bile duct

If residual cyst lining remains it can be cauterized cautiously with diathermy current.

The lower common bile duct is repaired with interrupted 5-0 PDS sutures just at its junction with the pancreatic duct, damage to which is avoided carefully. The divided distal duct is seen with the pancreatic duct on view and closure started.

Damage Common Bile Duct

STEP 6

The cyst is mobilized superiorly to the confluence of the right and left hepatic ducts.

Assess carefully for aberrant ducts, which may need to be divided separately.

The dissection may need to be extended along the extrahepatic course of the left duct if it is ectatic.

Some advocate extended liver resection for cysts extending into the left or right duct.

It is possible to anastomose to the cyst at the confluence of the ducts, if this extends more proximally, rather than performing liver resection.

A hepaticojejunostomy is performed in an end-to-side manner with a single layer of interrupted 4-0 PDS sutures. A Roux-en-Y limb of 70 cm of proximal jejunum should be used.

A drain should be left adjacent to the hepaticojejunostomy. The cyst is removed and the hepaticojejunostomy started (A, B).

Left Hepaticojejunostomy

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