Editing Hepaticojejunostomy


== Indications ==

* Part of the biliary tree has been excised
* Part of the tree has been damaged
* Definitive drainage procedure is required

== Principles ==

* 40cm alimentary limb
* Retrocolic biliary limb

== Technique ==

* Right subcostal incision
* Explore
** Check for accessory RHA arising from SMA in the lateral border of hepatoduodenal ligament
* Cholecystectomy
** Dissect Calot's, ligate and divide cystic artery and duct
** Expose junction of CBD and cystic duct
* Dissect CBD
** Incise peritoneum in lateral hepatoduodenal ligament
** Dissect along CBD back to planned division point (usually hepatic duct confluence)
** Encircle the duct with nylon tape and divide onto the tape to protect PV/IVC behind
** Evaluate proximal ducts - either IOC or choledochoscopy
** Deal with distal duct - dissect and resect
* Bring up jejunum
** Divide jejunum
** Retrocolic - to right of MCA
* Hepaticojejunostomy - Blumgart technique
** Start with 4/0 or 5/0 monofilament sutures in the anterior wall of CBD - 3-5mm apart, 3mm bites of CBD, clipped with needles on
** Enterotomy in anti-mesenteric border of the distal end of the Roux loop - just smaller than CBD
** Posterior wall - knots inside, place all sutures before tying - tie
** Complete anterior sutures on bowel side, and tie
* Jejunojejunostomy - end-to-side, two layer, continuous in this description
** Stay suture between anti-mesenteric edge of biliary limb (1cm proximal to staple line) and anti-mesenteric edge of alimentary limb
** Outer back wall suture parallel to staple line on biliary limb - leave needle on
** Excise staple line and make corresponding enterotomy on alimentary limb
** Inner back wall - knot on outside - full thickness bites on each side
** Continue round to inner front wall then tie
** Complete outer front wall
* Drain the bilio-enteric anastomosis

== Difficulties ==

* Small CBD - spatulate

[[Category:HPB]]