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- Part of the biliary tree has been excised
- Part of the tree has been damaged
- Definitive drainage procedure is required
- 40cm alimentary limb
- Retrocolic biliary limb
- 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
