BILIARY Flashcards
Intra-operative Choalgiogram
place clip at gallbladder-cystic duct jxn
Make a small incision in the ant wall of the cystic duct
12 gauge angiogram catheter is inserted subcostally, parallel to cystic duct
Cholangiogram catheter is then inserted through angiocath
Cholangiogram catheter grasped with right hand, and directed into cystic duct opening and clipped in place
Saline is flushed through to ensure there is no leak, and to flush out any air bubbles
C-arm of the fluoroscopy positioned
50% contrast is then flushed into CBD.
Want to see:
contrast flow into duodenum without obstruction
filling of R and L hepatic ducts
If cholangiogram is normal, remove catheter and continue with lap chole
If you see stone:
Glucagon 1mg IV is given to relax sphincter of Oddi
Rapidly flush CBD with 20 cc of saline. Repeat this multiple times
Choledochojejunostomy, Choledochoduodenostomy
- Position as per liver resection/whipple
Choledochoduodenostomy
mobilize CBD and duodenum (avoid anast tension later)
Suture CBD to duodenum using interrupted 4-0 vicryl
1.5 to 2cm incision on duodenum below suture line, and transverse or vertical incision on CBD
single layer anastomosis using interrupted 4-0 vicryl (Figure 2)
Choledochojejunostomy
Dissect out the anterior surface of the CBD
Transect (GIA) jejunum 15cm past ligament of treitz
Divide the mesentery containing the jejunal arcade between clamps to mobilize the jejunal limb to the CBD
Guide the jejunal limb through a defect in the transverse mesocolon toward the CBD
The anastomosis can be side to side or end to side (see figure 3).
If this is done, the CBD must be transsected, and the remaining stump oversewn with 4-0 absorbable.
One layer anastomosis with 4-0 absorbable suture
Use a t-tube to stent the anastomosis before the anterior wall is complete, and bring the long limb out through the anterior wall of the CBD
Fix the jejunum to liver capsule to avoid tension.
Make an end-to-side jejunojejunostomy is performed about 50-60 cm from the choledochojejunostomy to complete the Roux en Y.
Close the transverse mesocolon defect, Leave a drain in the RUQ
Sump syndrome
infrequent complication of a side-to-side choledochoduodenostomy.
Stenosis of the surgical anastomosis is a prerequisite.
food, stones, and other debris accumulate in the CBD distal to the stenotic anastomosis and proximal to the papilla,
overgrowth of bacteria results in suppurative cholangitis.
treated by combination of
ES
and
passage of a balloon through the distal CBD to sweep out debris from the duct.
Alternatively, it may be possible to extract debris and stones via the choledochoduodenostomy, obviating the need for a papillotomy; however, without a papillotomy and with a strictured choledochoduodenostomy, the sump syndrome may recur. (Slessinger)
Choledochojejunostomy
3-0 silk sutures. Enterotomies were made and the GIA stapler was introduced and fired. The staple line was checked for hemostasis and the enterotomy closed with a linear stapler/ two layers of sutures. The staple line was inspected for hemostasis. The staple line was inverted using interrupted 4-0 silk Lembert sutures.
The defect in the mesentery was then closed using running 3-0 Vicryl suture/ interrupted 3-0 silk sutures.
If sutured: A hand sewn two layer end-to-side enteroenterostomy was then performed between the proximal jejunal limb and the jejunum 40 cm distal to the roux limb using 3-0 Vicryl and 3-0 silk. The anastomosis was checked for integrity and noted to be widely patent.
The mesenteric defect was re-approximated with running 3-0 Vicryl suture/ interrupted 3-0 silk sutures.
The roux limb was also fixed to the mesocolon with interrupted silks.
distal end of the bile duct was then freshened to the point where there was clean tissue. Interrupted 5-0 PDS sutures were placed at 3 and 9 o’clock in the bile duct. An enterotomy was made in the roux limb ___ cm from the distal end on the antimesenteric border. The back wall of the end-to-side hepaticojejunostomy/ choledochojejunostomy was completed with interrupted 5-0 PDS. If stent:
A stent was fashioned from a 5 French pediatric feeding tube and placed across the anastomosis and into the left hepatic duct.
The stent was fixed to the roux limb with a chromic stitch/ not sutured in place. If t-tube: A T-tube was placed across the anastomosis.
The vertical limb was brought out of the duct 1 cm proximal to the anastomosis.
This was then brought out of through the abdominal wall through a stab incision. The anastomosis was then completed with interrupted 5-0 PDS on the anterior wall.
