CHAPTER 8 BENIGN BILIARY DISEASE AND ANASTOMOSIS

Exploration of the Common Bile Duct and Choledochoscopy

CHOLECYSTECTOMY

Open cholecystectomy for cholelithiasis is performed only in cases in which laparoscopic techniques do not allow a safe procedure. Cholecystectomy is also part of other operations, such as liver resection and pancreaticoduodenectomy.

Basically, two techniques are used to perform cholecystectomy: (1) the retrograde technique, with initial dissection of the hilar structures of the gallbladder in Calot’s triangle and (2) the anterograde or fundus-down technique, in which the gallbladder is first separated from the liver before the cystic duct and artery are transected.

PREOPERATIVE ASSESSMENT

Repeated attacks of biliary pain might be associated with chronic inflammation and dense adhesions or fibrous obliteration of Calot’s triangle. Liver function tests should be performed before cholecystectomy. Although patients submitted to cholecystectomy for gallstones will have undergone ultrasonography, more detailed investigations should be performed if there is any doubt as to the diagnosis. Antibiotic prophylaxis is used, with a single dose given at the time of anesthetic premedication.

OPERATION

Anatomy

The normal location of the neck of the gallbladder and the cystic duct is between the peritoneal surfaces within the right anterior part of the hepatoduodenal ligament (Chapter 1). The cystic artery runs transversely, forming with the cystic duct and bile duct the triangle described by Calot (1891). The triangle of cholecystectomy (often misnamed as Calot’s triangle) has for its upper limit not the cystic artery but the inferior surface of the liver (Rocko et al., 1981). Dissection of this area should show the anatomic structures and allow safe dissection (Fig. 8-1).

Figure 8-1 A, The triangle of cholecystectomy limited by the common hepatic duct, right hepatic duct, cystic duct, and liver. B, The triangle of Calot is limited by the common hepatic duct, cystic duct, and cystic artery.

Several abnormalities can alter the normal anatomy of the gallbladder (Fig. 8-2). The junction between the cystic duct and the common bile duct (CBD) also has many variations (Figs. 8-3 and 8-4) and probably represents the most important source of error leading to damage of the biliary tract during cholecystectomy.

Figure 8-2 Gallbladder located on the left side of the umbilical fissure and the ligamentum teres and attached to segment III of the liver.

Figure 8-3 Different modes of confluence of the cystic duct and common hepatic duct (see also Chapter 1).

Figure 8-4 Variations in the confluence of the extrahepatic bile ducts and cystic duct (see also Chapter 1).

The right branch of the hepatic artery may be transected inadvertently if it is not identified. An origin of the right hepatic artery from the superior mesenteric artery results in passage of the vessel posterolaterally to the CBD and behind the cystic duct, where it may be vulnerable. Intraoperative cholangiography, besides showing unidentified stones or pathology in the intrahepatic or extrahepatic bile ducts, also provides a precise view of the anatomy of the biliary ductal system.

Technique

The basic principles of dissecting close to the gallbladder and showing clearly any structure before ligature or section is performed must be respected. The cystic artery is identified and ligated only when its relation with the gallbladder has been shown clearly. Whenever the features in this region are not perfectly clear, the anterograde or fundus-down technique is considered safer.

Incision and Exposure

The incision may be a small right subcostal incision or a right transverse incision. A retractor, or the assistant’s hand, by pulling downward, provides a gentle traction on the hepatoduodenal ligament and allows good exposure. Gross gallbladder distention may obscure the cholecystectomy triangle, and puncture of the fundus and aspiration of bile are indicated. Bile culture is mandatory.

Retrograde Cholecystectomy

The peritoneum covering the hepatoduodenal ligament is incised. A clamp is placed at the fundus of the gallbladder, and the region of Hartmann’s pouch (Fig. 8-5) and of the cholecystectomy triangle is dissected. It is important to keep close contact with the gallbladder and to show the junction between the gallbladder and the cystic duct. A ligature is passed around the cystic duct but not tied. The cystic artery is dissected toward the gallbladder (see Fig. 8-5). The cystic duct is palpated to detect stones (Fig. 8-6). The cystic artery is ligated and transected (Fig. 8-7).

Figure 8-5 A, The gallbladder is seized with a clamp, and dissection of the cholecystectomy triangle is started. B, The cystic artery is in its normal position, above the cystic duct.

Figure 8-6 Palpation reveals a stone in the cystic duct, which may be “milked” back into the gallbladder.

Figure 8-7 The cystic artery is ligated close to the gallbladder wall.

A ligature or a clamp is placed at the junction of the gallbladder, and a cannula for cholangiography is inserted into the cystic duct (Fig. 8-8). This catheter is fixed by tying the ligature previously passed around the cystic duct. Cholangiography is then performed. The cystic duct may then be divided. The gallbladder is then dissected from its fossa with the help of gentle traction. The dissection should be kept close to the gallbladder, within the cystic plate (see Chapter 1).

Figure 8-8 The cystic duct is ligated at its junction with the gallbladder, and a catheter has been inserted for intraoperative cholangiography.

The gallbladder should be opened and checked for the presence of tumors. If there is any doubt, the suspect area is sent for frozen section.

The cholangiography catheter is removed and the cystic duct is suture ligated using absorbable suture material (Fig. 8-9). Insertion of a drain is, in most cases, unnecessary.

Figure 8-9 The catheter is removed, and the cystic duct is suture ligated. The cholecystectomy is now complete.

Antegrade or Fundus-Down Cholecystectomy

An incision of the gallbladder serosa overlying the fundus is performed, and a plane is developed by sharp dissection to allow entry to the cystic plate. The gallbladder is still vascularized via the cystic artery (Fig. 8-10). The cystic artery is encountered, seen to enter the gallbladder wall (Fig. 8-11), and divided. The infundibulum is dissected free down to the junction with the cystic duct. Cholangiography and cystic duct suture ligation are performed in the same way as described for the retrograde technique.

Figure 8-10 A, Anterograde or fundus-down cholecystectomy; the serosa of the gallbladder is incised 5 mm from the liver around the fundus. B, A plane is developed between the serosa of the gallbladder and the gallbladder wall, then between the liver and the gallbladder in the cystic plate, by sharp dissection.

Figure 8-11 As the anterograde dissection progresses toward the gallbladder neck, the cystic artery is identified, ligated, and divided.

Partial Cholecystectomy

Cholecystectomy may be hazardous because fibrosis and inflammation obscure the triangle of Calot (Fig. 8-12). It is judicious to open the fundus and to introduce a finger into the gallbladder to guide the dissection (Fig. 8-13). Impacted stones should be removed.

Figure 8-12 The common hepatic duct can be mistaken for the cystic duct when the region of the infundibulum cannot be delineated because of fibrosis and inflammation.

Figure 8-13 A, The fundus of the gallbladder has been opened and a finger introduced into the gallbladder for palpation. B, Partial cholecystectomy. The superficial part of the fundus and body of the gallbladder has been excised, leaving in place its attachment to the liver and the infundibulum. The remaining mucosa is removed by curettage and electrocoagulation, and a drain is placed near the infundibulum.

If no bile appears, the cystic duct is probably occluded by fibrosis and inflammation. A partial cholecystectomy is the safest procedure in this situation (see Fig. 8-13). No attempt at defining and ligating the cystic duct should be made. If a gush of bile appears when a large impacted stone is removed from the infundibulum, a cholecystocholedochal fistula is probably present (Mirizzi syndrome type II). It is advisable to keep the opened distal part of the gallbladder intact to allow performance of a cholecystoduodenostomy or a cholecystojejunostomy. Attempted direct repair of the fistula is unnecessary, difficult, and potentially hazardous (Baer et al., 1990).

INTRAOPERATIVE PROBLEMS

Intraoperative problems have been related to three main causes: dangerous surgery, dangerous anatomy, and dangerous pathology. Insufficient preoperative assessment of a complicated situation is another avoidable reason for intraoperative difficulties.

Dangerous surgery arises from inadequate or imprecise observation of the technical principles of cholecystectomy, insufficient experience, inadequate incision and exposure, or inadequate assistance. Some of the anatomic variations that have been mentioned previously (see Figs. 8-3 and 8-4, Chapter 1) are particularly dangerous.

Dangerous pathology includes chronic or acute inflammation, which results in obscured anatomy and increased vascularity in the region of the cholecystectomy triangle (see Fig. 8-12). Portal hypertension is associated with increased venous collateralization, which makes the dissection hemorrhagic and dangerous. Partial cholecystectomy is advocated in both situations.

Hemorrhage in the cholecystectomy triangle represents potential danger because attempts at hemostasis by placing clamps with obstructed and insufficient view may result in inadvertent clamping of the right or proper hepatic artery or of the bile duct (Fig. 8-14). In this situation one should first attempt to control the hemorrhage by digital compression or by clamping the hepatoduodenal ligament (Fig. 8-15) to localize its precise origin. Grasping the bleeding vessel should be done with precision so as to limit the risks of including another structure in the ligature.

Figure 8-14 Blind placement of clamps for hemostasis can result in lesions of the hepatic artery or bile duct.

Figure 8-15 Hemorrhage should be controlled first by manual clamping of the hepatoduodenal ligament until a better view is obtained, making precise hemostasis possible.

EXPLORATION OF THE COMMON BILE DUCT AND CHOLEDOCHOSCOPY

INDICATIONS FOR COMMON BILE DUCT EXPLORATION

The purpose of CBD exploration for choledocholithiasis is to detect and remove all stones within the bile duct system. The absolute indications for CBD exploration are (1) palpable stones in the CBD, (2) jaundice with cholangitis, and (3) a stone seen at intraoperative cholangiography (Fig. 8-16). Even where local endoscopic, radiologic, or laparoscopic expertise coexists, there are still indications for open choledochotomy:

1. Patients with multiple CBD stones who are not candidates for endoscopic sphincterotomy or in whom endoscopic approaches are compromised (e.g., the presence of duodenal diverticula or after previous gastrectomy)

2. Patients with gallstones and concomitant jaundice or acute suppurative cholangitis who cannot be managed by endoscopic sphincterotomy

3. Patients in whom an open cholecystectomy is performed for different reasons, such as suspicion of cancer or the presence of a biliary-enteric fistula or Mirizzi syndrome, who should have palpation of the CBD and operative cholangiography performed; if CBD stones are seen, choledochotomy may be necessary.

4. Patients in whom, during laparoscopic cholecystectomy, concomitant CBD stones are found by cholangiography, and the surgeon decides that they cannot be removed intraoperatively at laparoscopy or postoperatively by endoscopic sphincterotomy

Figure 8-16 Operative cholangiography showing a small stone in the nondilated, distal, intrapancreatic bile duct, unsuspected by the surgeon.

SURGICAL TECHNIQUES FOR EXPLORATION OF THE COMMON BILE DUCT

Exploration of the CBD should be through a supraduodenal choledochotomy. Although impacted stones at the ampulla may be broken down and removed by a supraduodenal approach, they probably should be removed by means of a transduodenal sphincteroplasty because it is less traumatic.

Supraduodenal Choledochotomy and Exploration of the Common Bile Duct

Exposure

The liver is retracted superiorly and the hepatic flexure of the colon superiorly. The lesser omentum and stomach are retracted to the left. A Kocher maneuver is performed (Fig. 8-17).

Figure 8-17 A, The gallbladder has been removed. The dotted line indicates the incision in the retroperitoneum to allow mobilization of the duodenum by the Kocher maneuver (B).

Technique

The opening should be in the lowest part of the supraduodenal CBD (Fig. 8-18). A cystic duct lying anterior or closely applied to the CBD can be easily opened in error (Fig. 8-19). Bile is aspirated and sent for culture.

Figure 8-18 Two fine stay sutures of 3-0 polydioxanone suture (PDS) or 3-0 polyglactin 910 (Vicryl) are used to lift and render the common bile duct (CBD) tense for an incision about 1 to 2 cm long, depending on the size of the duct and the size of the stones. If the CBD is not made tense, damage can be done to the posterior wall or an irregular incision can be made.

Figure 8-19 A, The cystic duct may lie anterior to the common bile duct (CBD) and may be opened in error. B, The cystic duct may run parallel to the CBD with a low entrance mimicking a dilated duct.

A Fogarty balloon catheter (Fogarty et al., 1968) is introduced into the CBD (Fig. 8-20) and passed into the duodenum (Fig. 8-21). The balloon is inflated, and the catheter is withdrawn until it impinges against the papilla. The second part of the duodenum and posterior surface of the head of the pancreas are palpated, and the balloon is identified. Any stone present usually can be felt against the shaft of the catheter. The balloon is deflated and gently withdrawn through the papilla; this is detected by a sudden easing of the pull on the catheter. The balloon is reinflated immediately (Fig. 8-21). The catheter is held by the syringe in the left hand; with gentle traction superiorly by forceps held in the surgeon’s right hand, the catheter is gradually pulled up to the choledochotomy site (Fig. 8-22), taking care to prevent any stone from slipping into the proximal biliary tree.