STEP SBiliary anastomosis

In patients with biliary atresia, pediatric patients with small-diameter bile ducts, or in patients with primary sclerosing cholangitis and a sclerotic common bile duct, a hepatico-jejunostomy should be performed. In other cases, a duct to duct anastomosis can be performed in a similar way as for orthotopic or right living donor liver transplantation.

A small hole is made in the Roux-en-Y limb close to the proximal end. A 4-Fr polyvinyl alcohol tube is inserted through the hole into the intestinal lumen as an external stent and is led out of the intestinal wall again. Two double-armed 6-0 PDS sutures are placed on the right and left corner of the graft hepatic duct. The stitch of the right corner is pulled with a small clamp to open the hepatic duct. Anastomosis of the posterior wall is made first with a running suture using the stitch of the left corner (A). After completion of the posterior wall, the inside needle of the stitch of the right corner of the graft is passed through the corner of the jejunum from inside to outside. After insertion of the tip of the stent into the duct lumen, anastomosis of the anterior wall is made using another needle of the left corner in running fashion (B). When the diameter of the hepatic duct is small, an incision on the anterior wall along the axis can be used to enlarge it.

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