Transduodenal exploration of the bile duct

In this operation the bile duct is approached across the duodenum and through the ampulla. It is usually combined with a sphincteroplasty. The duodenum is fully mobilized and a longitudinal incision is made in the right lateral wall over the ampulla. A probe is then passed into the bile duct and the ampullary sphincter is divided with scissors. Fine catgut sutures are placed to appose the mucosa of the bile duct to the duodenum and the stones are then extracted with Desjardin forceps. The choledochoscope can be used to ensure that all the stones have been removed and the duodenum is then closed. The advantage of this approach is that any missed stone will pass spontaneously. The disadvantage is the risk of pancreatitis from interference with the ampulla. Most patients who need a transampullary approach to their bile ducts are better treated endoscopically.

 

Choledochoduodenostomy

Occasionally an alternative to closure of the common bile duct over a t-tube after a supraduodenal exploration is a choledochoduodenostomy. Provided the bile duct is more than 15 mm in diameter the operation is quick and easy to perform, and there are no worries about retained stones. The vertical incision in the common bile duct is sutured to a longitudinal incision in the duodenum with a single layer of stitches. Results in elderly patients are satisfactory, but in patients who have had the anastomosis for a number of years recurrent cholangitis may develop. This is known as the & lsquo; sump syndrome& rsquo;: infection arises from stones and vegetable matter which collect in the retroduodenal portion of the bile duct between the anastomosis and the ampulla. There may also be stenosis of the choledochoduodenostomy. Endoscopic sphincterotomy of the ampulla and balloon dilatation of the anastomosis may alleviate the symptoms, but treatment is not very satisfactory.

 

Biliary peritonitis

Percutaneous cholangiography is the most common cause of bile peritonitis, although there is usually blood present as well. Provided the signs are localized treatment can be conservative, although if there is a significant biliary obstruction it is likely that the leak will persist. It is still wise to perform percutaneous cholangiography only when it is also possible to relieve any obstruction, either radiologically or at an operation within 12 h.

 

Occasionally the acutely inflamed gallbladder perforates and fills the peritoneum with bile; this may also happen if a t-tube is removed too soon. Bile peritonitis can be difficult to diagnose clinically because uninfected bile is often not particularly irritant and the signs may be very subdued. Once the diagnosis is made laparotomy is usually needed, but for smaller more localized collections, as may occur after a percutaneous cholangiogram, ultrasound guided drainage may be sufficient.

 

Benign biliary structure

Postoperative stricture

Almost all injuries to the bile ducts occur during an easy cholecystectomy; the most common mistake is to confuse the common hepatic duct for the cystic duct. The & lsquo; duct& rsquo; is tied and divided, thus excising a length of the common hepatic duct in the hilum of the liver (Fig. 38) 1261. A similar injury can occur during laparoscopic cholecystectomy. Very few patients have undergone operative cholangiography.

 

Aetiology and prevention

Poor surgical technique is the most common cause of a significant biliary injury. The precise individual anatomy has not been correctly identified, although various anatomical and pathological factors may have made this difficult. The surgeon thinks that narrow ducts are too narrow to be the bile duct. The cystic duct may run alongside the bile duct for a distance, which leads the surgeon into the wrong plane. Anatomical variations of the main ducts also predispose to damage. The cystic duct may enter the right hepatic duct; sometimes there is no right duct, and the right anterior hepatic duct runs very close to the cystic duct. Such anatomical variations are one of the justifications for performing operative cholangiography. During the operation excessive fibrosis and inflammation in the porta hepatis and sudden inadvertent haemorrhage are both dangerous and put the bile ducts at risk.

 

Inadequate exposure is the cause of most injuries. An adequate and correctly placed initial incision is essential Excessive traction is to be avoided and it is not necessary to trace the cystic duct right to the junction with the bile duct. Once any difficulty is encountered a cholangiogram is invaluable.

 

Two new operations have increased the risks of bile duct injury. Minicholecystectomy is undertaken through the smallest possible incision and exposure is therefore minimal. Dissection must stay immediately adjacent to the gallbladder wall until the cystic duct is reached. Correctly performed, the operation is safe, but there is no margin for error. Failure to identify the anatomy correctly is associated with the bile duct injuries which occur at laparoscopic cholecystectomy, but the causes are different. The two-dimensional television image causes difficulties in orientation and judgement of depth, and the necessary manual skills are strange to most surgeons. Exposure is not normally a problem and indeed the view of the anatomy, particularly in obese patients, is excellent (Fig. 35) 1258. If difficulty is encountered nothing must be divided until the anatomy is clear. A cholangiogram may help and an open operation must be undertaken if this would be a safer option.

 

Diagnosis

In about one-quarter of patients the injury is recognized at the time of operation and in a further third it comes to light within the next month. Most of these latter patients present with jaundice, sometimes with cholangitis and sometimes with a biliary fistula. The remaining patients present months or years later with recurrent cholangitis. In the early postoperative period ERCP is the most useful imaging technique for displaying the extent of the damage; this may provide an opportunity to place a stent if this is appropriate. Contrast medium injected along the track of a fistula may define the injury and the bile ducts adequately.

 

In patients who present later, both ERCP and percutaneous transhepatic cholangiography may be needed to display the superior and the inferior aspects of the stricture. It may also be possible to relieve the obstruction by placing a self expanding metal stent across the structure. These patients with long-standing incomplete obstruction and infection have a significant risk of liver damage and portal hypertension. The presence and the severity of these complications require investigations such as a liver biopsy and oesophagoscopy looking for varices.

 

Treatment

Many surgeons realize with horror during a cholecystectomy that they have just tied the bile duct. The tie should be removed and nothing further needs to be done. Strictures do not develop afterwards.

 

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