Technical aspects of surgical repair of complex iatrogenic biliary strictures

Abstract

Background: Currently, iatrogenic bile duct injury during cholecystectomy remains a major concern in biliary surgery due to associated morbimortality, and optimal management is still a medical challenge. Definitive treatment depends on type of injury and time of diagnosis. Minor injuries can be successfully treated using endoscopic techniques with placement of stents. Nevertheless high-level injuries Bismuth 3 and 4 can accomplish good outcome with surgical reconstruction. At our Unit patients are referred to late repair, either for primary late repair or for retreatment after fail of bilioenteric reconstruction. Our aim is demonstrated the surgical technique to reconstruction of high-level biliary injury. Methods: In this video, it is demonstrated a technique to surgical reconstruction of a biliary stricture, Bismuth type 3-4, that involves the technique described by Machado et al. in 1986 associated to the dissection of right biliary duct as described by Straberg et al. in 2001. Results: A 29-year-old female was diagnosed with bilioenteric anastomosis (BEA) stricture (Bismuth 3). The BEA has been performed initially to repair biliary injury during laparoscopic cholecystectomy by the same team. Later patient was referred to our Center and submitted to a new side-to-side BEA. Patient was submitted to general anesthesia and received prophylactic ceftriaxone and metronidazole. Bilateral subcostal incision was performed. After identification of previous biliary anastomosis, an incision was performed in segment 4B just above hilar plate. Round ligament was dissected, umbilical fissure was opened and the liver bridge between segment 4 and 2/3 was divided until reaching left bile duct underside of segment 4. Left bile duct was opened anteriorly, exposing the entrance of left and right bile ducts. Dissection of hilar plate was performed continuing toward the right, passing into the liver at base of segment 5, circling the right duct in direction of right portal vein. Right duct was opened 0.5-to-1cm anteriorly. MR cholangiography and the final aspect of biliary dissection are showed in the Video. The liver is opened trough round ligament, crossing above hilar plate at the base of segment 4B, and circling right hepatic duct at segment 5. Note the large open of right and left hepatic ducts, exposing a health mucosa, and showing the ostia of posterior and anterior right hepatic ducts and left ducts. A Roux-en-y side-to-side hepaticojejunostomy is performed using a continuous running suture of 5.0 PDS. At the end, bilateral TRU-CUT liver biopsies were performed. A flat silicone drain was placed posteriorly to the anastomosis. Postoperative period was uneventful, without any complications. The pathologic examination revealed periportal non-ductopenic fibrosis, without bridging. Conclusion: Surgical repair of complex biliary strictures highly located can achieve excellent Results even when previous surgery has failed when performed in specialized Centers. Roux-en-Y hepaticojejunostomy should be performed with adequate mucosa apposition without the need of transanatomosis biliary stent.