Hepp-Couinaud bilioenteric anastomosis

In the Hepp-Couinaud hepaticojejunostomy deep in the hepatic hilum, the efferent jejunal limb is anastomosed with the extrahepatic left hepatic duct side-to-side. This type of biliodigestive anastomosis deep in the hepatic hilum is indicated in stenoses extending to the junction of the left and right hepatic ducts, but where the common hepatic duct is still intact.

Otherwise, the surgical technique is identical with Standard bilioenteric anastomosis.

• The goal is to fashion as wide an anastomotic opening as possible.
• The single row of interrupted suture encompassing all layers should be leak-proof from the beginning.
• Precisely adapt the mucosa of the hepatic duct to that of the jejunum.

At the hepatic portal, expose the hepatic artery proper and the left and right hepatic arteries. Free the entire circumference of the common bile duct and common hepatic duct.

After freeing the entire circumference of the CBD, transect the common hepatic duct at the hepatic hilum. Here, the two lumina of the left and right hepatic ducts become visible. Excise a segment of the CHD and close the duodenal end of the CBD with an absorbable running suture (Vicryl® 3-0) (not shown). Ensure delicate hemostasis, possibly with 6-0 PDS, at the hilar transection of the common hepatic duct, if necessary.

Due to the expected anastomotic contraction, expand the left hepatic duct in the Hepp-Couinaud technique. To this end, incise the anterior wall of the left hepatic duct longitudinally.
Expand the junction of the left and right hepatic ducts by resecting the posterior spur and suture the posterior wall.

For better clarity, preplace the double armed interrupted PDS 5-0 sutures of the anterior wall including the corner sutures. 

Mobilize the second jejunal loop by transecting it with the GIA stapler and invert the staple with sutures. Bring the efferent jejunal limb into the right upper quadrant of the abdomen posterior to the hepatic flexure. Fashion the local U-shaped antimesenteric incision in the pulled up efferent limb.

Next, preplace the interrupted PDS 5-0 sutures of the posterior wall. Now tie the knots of the posterior wall, with the knots being intraluminal.

Now complete the anastomosis by tying the preplaced double-armed interrupted sutures of the anterior wall. In this case, the knots will be extraluminal. This completes the biliodigestive anastomosis deep in the hepatic hilum.
Close the slit in the mesentery, and place 2 Easy-Flow drains at the anastomosis.