Perioperative management - Anastomosis technique, biliodigestive, according to Hepp-Couinaud

• Reconnection of the bile ducts after pancreatic head resection
• Bypass anastomosis in non-resectable tumor obstructions of the bile ducts and papilla
• Accidental choledochus injuries
• Congenital or acquired strictures of the bile ducts

• Relevant comorbidities with inability for surgery or anesthesia

In cases of previous iatrogenic injury to the bile ducts, such as during a laparoscopic cholecystectomy, preoperative diagnostics including vascular imaging (Angio-CT / Angio-MR) and visualization of the biliary system (ERCP/MRCP) are necessary.

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General information about the risks of surgery:

• Bleeding
• Thrombosis
• Embolism
• Infections
• Vascular-nerve injury
• Rebleeding
• Injury to adjacent organs

Specific information:

• Dehiscence with bile leakage
• Stenosis with intermittent cholangitis as a late complication
• Peritonitis

• Intubation anesthesia
• Epidural catheter (Peridural catheter)

• Supine position
• Left arm adducted
• Right arm extended

The surgeon stands to the right of the patient, the first and second assistants stand to the left of the patient, and the scrub nurse stands to the left, at the foot of the first assistant.

Retraction systems for access to the upper abdomen, e.g., Ulmer and Zenker hook systems

Medical Aftercare
Crucial is early postoperative extubation and adequate pain management (epidural analgesia!). Follow the link here to PROSPECT (Procedures Specific Postoperative Pain Management).
Follow the link here to the current guideline: Treatment of acute perioperative and post-traumatic pain.

• perioperative antibiotics 48 – 72h postoperatively
  Start perioperative antibiotics with the induction of anesthesia, e.g., combination of Cefotaxime 3 × 2 g and Metronidazole 3 × 0.5 g i.v.; in case of penicillin allergy, use Ciprofloxacin 200mg 1-0-1 instead of Cefotaxime
• close laboratory monitoring
• determination of bilirubin from the drainage secretion
• removal of drains depending on secretion amounts and the aforementioned values
• removal of epidural catheter by anesthesia on the 3rd – 6th postoperative day
• PPI prophylaxis: initially i.v., then orally

T-Drainage
In cases of a thin-caliber common bile duct and/or difficult anastomotic conditions, it is advisable to insert a T-drainage, caliber 2.5 – 3.5 mm. The drainage remains in place for 7 days postoperatively, followed by contrast medium imaging under fluoroscopy. If anastomotic insufficiency is excluded, the drainage is clamped and the anastomosis-near EasyFlow drainage is removed. The T-drainage is left in place for 6 – 8 weeks (the patient is discharged in the meantime) and then subjected to contrast medium imaging again. In regular anastomotic conditions, the drainage is removed under antibiotic prophylaxis (according to the antibiogram from the intraoperatively taken bile duct swab or Levofloxacin 500 mg 1 – 0- 1 orally). Laboratory and ultrasound checks the following day are recommended. In case of signs of infection in the laboratory, fever, etc., occasional inpatient monitoring for a few days is required.

Thrombosis Prophylaxis
Thrombosis prophylaxis is carried out with a low molecular weight heparin. Follow the link here to the current guideline: Prophylaxis of venous thromboembolism (VTE).

Mobilization
Already on the day of the operation

Physical Therapy
The physical therapist assists with this mobilization and additionally performs intensive breathing exercises.

Dietary Progression
Remove the nasogastric tube by the 1st postoperative day at the latest, then begin dietary progression.

Bowel Regulation
Bowel movement usually resumes spontaneously after 3 – 4 days. A mild laxative can be used to assist if necessary.

Incapacity for Work
Depending on individual convalescence, also depending on further therapeutic measures, e.g., chemotherapy.