Standard bilioenteric anastomosis

  • Universität Witten/Herdecke

    Prof. Dr. med. Gebhard Reiss

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  • Biliary tract

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    The bile ducts drain bile from the liver into the duodenum. This way, the bile with its bile acid aids in the digestion of lipids in the food. The biliary tree originates in the small ducts within the liver which confluence to segment ducts and finally the left and right hepatic duct which descend from the liver. Their union forms the common hepatic duct (CHD – ductus hepaticus communis). Along its course to the duodenum it is joined by the cystic duct (ductus cysticus) from the gallbladder (vesica biliaris). The union of the common hepatic duct and the cystic duct forms the common bile duct (CBD – ductus choledochus) which drains into the duodenum. The major duodenal papilla (papilla of Vater) is a sphincter muscle controlling the bile flow from the common bile duct into the duodenum.

  • Jejunum

    • The jejunum is the second of three sections of the small intestine. It extends from the duodenum to the ileum.
    • Its colloquial German term of “Leerdarm” or “empty bowel” stems from the fact that in most dead patients it is empty.*

    The jejunum is plicated in numerous loops and with its mesentery attaches to the posterior abdominal wall. The corresponding segment of the mesentery is called mesojejunum. When considered together with the ileum, which begins at the jejunum and terminates at the cecum, the radix mesenterii or root of the mesentery extends from the duodenojejunal flexure to the ileocecal valve.

    • Since the loops of the jejunum are quite mobile, they shift their positions. While the beginning of the jejunum is well defined by the duodenojejunal flexure at the level of the second lumbar vertebra, the boundary between the jejunum and ileum is not well defined.
    • Like any other hollow viscus, the jejunum is lined with a mucous membrane (tunica mucosa). On the outside, the mucous membrane is enclosed by a double layer of smooth muscle (tunica muscularis), while the serosa is a reflection of the peritoneum over the exterior of the jejunum.
    • The superior mesenteric artery supplying the jejunum, ileum, appendix, ascending colon and the proximal two thirds of the transverse colon courses in the proximal section of the mesenteric root.
    • The jejunal arteries are branches of the superior mesenteric artery and supply the jejunum with blood. The veins of the jejunum drain into the superior mesenteric vein which parallels the superior mesenteric artery on the right and then courses posterior to the head of the pancreas to the portal vein.
    • The jejunum is primarily innervated by the enteric nervous system. Peristalsis is controlled by the mesenteric plexus (Auerbach plexus), while the mucous membrane is innervated by the submucous plexus (Meissner plexus). In addition, the jejunum is also regulated by the sympathetic and parasympathetic nervous systems (in particular the vagus nerve).

    ieiunus is Latin for fasting, hungry, meagre *

  • Kantonspital Baden AG

    Dr. Dominique Sülberg

  • klinikum

    Prof. Dr. Uhl

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  • Indications

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  • Contraindications

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  • Preoperative diagnostic work-up

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  • Special preparation

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  • Informed consent

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  • Anesthesia

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  • Positioning

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  • Operating room setup

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  • Special instruments and fixation systems

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  • Postoperative management

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date of publication: 21.05.2012
  • Kantonspital Baden AG

    Dr. Dominique Sülberg

  • klinikum

    Prof. Dr. Uhl

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  • Principle

    114-2

    The gold standard in bilioenteric anastomosis is retrocolic end-to-side Roux-en-Y hepaticojejunostomy with a segment of the proximal jejunum.

    Here, the preferred bilioenteric anastomosis is established proximal to the cystic duct and about 2-3 cm distal to the union of the hepatic ducts.

    • The opening of the anastomosis should be as wide as possible (if the common hepatic duct is too small it may be enlarged with the Hepp-Couinaud technique)
    • The single row of interrupted suture encompassing all layers should be leak-roof from the beginning and
    • precisely adapt the mucosa of the hepatic duct to that of the jejunum.
  • Exploration – exposure of the hepatoduodenal ligament

    114-3

    The anastomosis will be explained as part of the Whipple procedure for cancer of the pancreatic head. One modification of the bilioenteric anastomosis (hilar hepatojejunostomy) is found under Hepp-Couinaud technique for bilioenteric anastomosis,

    In the hepatoduodenal ligament expose the proper hepatic artery, portal vein and the CHD / CBD. Free the entire circumference of the duct.

  • Exposing the CBD/CHD

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    Once the circumference of the duct has been freed completely, it is divided immediately proximal to the junction of the cystic duct. The duodenal end of the CBD is closed with an absorbable running suture (Vicryl® 3-0) (not shown). The part to be anastomosed is temporarily blocked with bulldog forceps.

    Note: Because of the clinically significant preoperative obstruction of the CBD, it had been decompressed before surgery by a blue drain through a stent.

  • Dissecting the jejunal loop

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    A detailed description of the Roux-en-Y technique is found here Gastrointestinal anastomosis, Roux-en-Y esophagojejunostomy

    Free the 2nd jejunal loop. Identify the mesenteric vascular arcades by transillumination and dissect with the Ligasure. Divide the loop at a location with confirmed blood flow. Pull up the descending Roux-en-limb through a window in the mesentery to the right of the middle colic artery. Verify that the mesentery is not twisted. Stitch over the stapled blind end with a running seromuscular suture PDS 5/0.

  • Creating the bilioenteric anastomosis – suturing the posterior wall

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    First, freshen the divided margin of the bile duct and place Prole 5/0 stay sutures.

    Incise the jejunal loop on its antimesenteric aspect over the same length as the diameter of the bile duct. Attach the jejunal mucosa to the intestinal wall with four interrupted sutures PDS 6/0, which will prevent it from slipping back. Now place the atraumatic orientation sutures in the middle of the anterior and posterior wall and the corner sutures, all with PDS 5/0. This defines the anterior and posterior wall and ensures even distribution of the anastomotic margins in the bile duct and jejunum. Since this anastomosis cannot be flipped over, the anastomosis of the posterior wall is performed first.

    This is carried out with interrupted sutures inside-out through all layers, with the knots located within the lumen. Depending on the diameter of the bile duct, this should require at least seven sutures with PDS 5/0 or 6/0.

    Note: For a clearer view, first place all sutures before tying their knots. After the sutures have been tied, cut off one suture end and collect the remaining end together with the others in a clamp. This makes it easier to place any additional sutures into gaps. Once the posterior wall has been completed cut off these remaining suture ends.

  • Creating the bilioenteric anastomosis – suturing the anterior wall

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    This carried out with interrupted sutures outside-in through all layers, employing the same technique as with the posterior wall.

    Note: For a clearer view, the four sutures anchoring the mucosa (see surgery figure step 4) have been left out of this figure.

  • Closing the mesenteric window

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    Inspect the anastomosis. Close the mesenteric window, irrigate and control any bleeding. Place an EasyFlow drain near the anastomosis.

  • Kantonspital Baden AG

    Dr. Dominique Sülberg

  • klinikum

    Prof. Dr. Uhl

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  • Intraoperative complications

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  • Postoperative complications

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  • Klinikum Ingolstadt

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