This document discusses various biliary conditions and procedures. It begins by listing different bile duct abnormalities and causes of gallstone disease. Various biliary reconstruction procedures are then described such as end-to-end anastomosis, choledochojejunostomy, and hepaticojejunostomy. Key steps for biliary reconstruction surgery are outlined including exposure, adhesiolysis, and irrigation. Complications are noted and T-tube placement is described as a option for distal bile duct injuries or palliation.

7. RASD
RPSD
Low junction RPSD
Normal
Separate junction
Cystic duct from rp

9. • 1/3 rd of patients
• Segmental
• Underneath Glisson’s capsule
• Bile Leak post cholecystectomy
THESE ARE NOT MY DUCTS !!! Hubert von Luschka

14. GALL STONE RELATED
CHOLECYSTITIS
CHOLEDOCHOLITHIASIS
CHOLANGITIS
PANCREATIC MALIGNANCY
HEPATIC MALIGNANCY
INTRA HEPATIC BILIARY MALIGNANCY
GALL BLADDER MALIGNANCY

17. ENDTO END
ANASTOMOSIS
CHOLECYSTO-
JEJUNOSTOMY
RYHJ
CHOLECYSTO-
DUODENOSTOMY
• Recognized during the original
surgery
• Sharp injury
• Less than a circumference of
the duct
• Ends are not more than 2 cm
away
• Without extensive tissue loss

18. • Well vascularized ->
• Tension free
• Duct to Mucosa
• Ischemia and Fibrosis to be avoided ->

19. Self Retaining Retractors –
Thompson
Note: Must be placed after
dividing the falciform to avoid
lacerating the liver.
Ambient Light – Cold light source
like a head light
Magnifying Loupes

20. Adhesiolysis
Cholecystectomy
(if not already
performed)
*** Most biliary reconstructions
involving the confluence starts by
lowering the LHD
Subcostal/Hockey
Stick, three finger
breadths below
costal margin
Modified
Makuuchi

21. • Culture must be sent
• Irrigation of the Ductal System
with copious amounts of saline

22. • Suitable for HJ (Hepp Couinaud )
(HeppCouinaud )

23. • Rt. Hepatic Artery may lie Anterior to the duct here.
• When

25. Modified after Blumgart
The anterior layer of sutures on the bile
duct is inserted first, with the sutures being
passed from the inside out.
The anterior layer of sutures is elevated to
clearly display the posterior ductal wall.
The posterior row of sutures is placed and
tied, using full thickness of duct and
intestine with mucosa to mucosa
approximation.
The needles of the anterior layer are now
passed through the jejunal wall from the
outside inward. The entire anterior row of
sutures is completed before being securely
tied with the knots within.

28. • Strasberg et al

29. Side to SideY shaped RYHJ for a narrow biliary
ductal system
Side to side Choledocho jejunostomy

30. End to Side RYHJ Side to Side RYHJ

31. T-Tube
Long silicon tube
with several holes

32. • Distal Bile duct Injuries – E1
• Primary CBD stones with distal
obstruction
• Palliation for Periampullary
carcinoma
• Biliary Stricture from Chronic
Pancreatitis

35. Lap RYHJ

38. “ABNORMAL”

39. Thank you …