1. Direct repair of theDirect repair of the
common bile ductcommon bile duct
(CBD) in iatrogenic(CBD) in iatrogenic
injuriesinjuries
ByBy
Youssri S. GaweeshYoussri S. Gaweesh
Prof. of surgeryProf. of surgery
Alexandria universityAlexandria university
2. Iatrogenic CBD injuriesIatrogenic CBD injuries
It has long been considered thatIt has long been considered that
iatrogenic injuries can best beiatrogenic injuries can best be
repaired with biliary entericrepaired with biliary enteric
anastomosis between a Roux loopanastomosis between a Roux loop
of jejunum and the proximallyof jejunum and the proximally
dissected segment of the extradissected segment of the extra
hepatic biliary tree.hepatic biliary tree.
3. Iatrogenic CBD injuriesIatrogenic CBD injuries
The traditional teaching includes aThe traditional teaching includes a
mucosa to mucosa tension freemucosa to mucosa tension free
anastomosis with or without stentinganastomosis with or without stenting
between the biliary segment and thebetween the biliary segment and the
defunctionalized jejunal loop, todefunctionalized jejunal loop, to
avoid ascending reflux cholangitis.avoid ascending reflux cholangitis.
4. Iatrogenic CBD injuriesIatrogenic CBD injuries
The idea of using the proximal and theThe idea of using the proximal and the
distal biliary tree is tempting because ofdistal biliary tree is tempting because of
the use of the mechanism of thethe use of the mechanism of the
sphincter located down around thesphincter located down around the
insertion of the CBD to avoid refluxinsertion of the CBD to avoid reflux
cholangitis and to regulate the entry ofcholangitis and to regulate the entry of
bile into the duodenum together withbile into the duodenum together with
pancreatic secretions to effect the bestpancreatic secretions to effect the best
mix between digestive enzymes andmix between digestive enzymes and
food.food.
5. Iatrogenic CBD injuriesIatrogenic CBD injuries
It has long been considered that theIt has long been considered that the
distal part of the CBD is notdistal part of the CBD is not
dissectible from within the pancreasdissectible from within the pancreas
which proved not to be truewhich proved not to be true
because of the presence of abecause of the presence of a
definite fascial sheath around itdefinite fascial sheath around it
helping dissection withouthelping dissection without
endangering the blood supplyendangering the blood supply
6. Iatrogenic CBD injuriesIatrogenic CBD injuries
Proper Khorization of theProper Khorization of the
duodenum ,after distal segmentduodenum ,after distal segment
dissection can compensate for atdissection can compensate for at
least 3 cm length, thus the distalleast 3 cm length, thus the distal
segment reaching the proximal onesegment reaching the proximal one
without tension and enabling thewithout tension and enabling the
surgeon to do a mucosa to mucosasurgeon to do a mucosa to mucosa
tension free anastomosistension free anastomosis
7. Iatrogenic CBD injuriesIatrogenic CBD injuries
A T tube inserted in the distalA T tube inserted in the distal
segment and bridging thesegment and bridging the
anastomotic line with part of theanastomotic line with part of the
horizontal limb of the T tube ishorizontal limb of the T tube is
enough as a stent for theenough as a stent for the
anastomosis .anastomosis .
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18. Alternative stentingAlternative stenting
If using a T tube is difficult or impossible forIf using a T tube is difficult or impossible for
small diameter of the distal limb, one cansmall diameter of the distal limb, one can
use plastic stents used in ERCPuse plastic stents used in ERCP
Either 7 french or 10 french stents areEither 7 french or 10 french stents are
usedused
Insertion starts first in the distal limb until itInsertion starts first in the distal limb until it
protrudes into the duodenumprotrudes into the duodenum
The stent is cut to allow two cm length to beThe stent is cut to allow two cm length to be
introduced proximallyintroduced proximally
19. Alternative stentingAlternative stenting
Three or four 4/0 or 5/0 vicryl sutures areThree or four 4/0 or 5/0 vicryl sutures are
inserted without approximation first ininserted without approximation first in
order to assure a mucosa to mucosaorder to assure a mucosa to mucosa
suturingsuturing
Approximation is done with the stentApproximation is done with the stent
introduced to the proximal cut end withintroduced to the proximal cut end with
direction towards the right ductdirection towards the right duct
With the assistant pushing the kochirzedWith the assistant pushing the kochirzed
duodenum upwards to assure tension freeduodenum upwards to assure tension free
20. ResultsResults
The results of ten cases doneThe results of ten cases done
within the last year (August 2004within the last year (August 2004
to July 2015) are showing perfectto July 2015) are showing perfect
outcome with only one caseoutcome with only one case
needing reoperation for hepaticoneeding reoperation for hepatico
duodenal anastomosis.duodenal anastomosis.
21. ERCP done for second case (N.M.) demonstrating complete cut of
distal segment
22. T tube cholangiography done 3 months after repair before tube
extraction (second patient N.M.)
23. MRI after one year , patient is presenting by itching without jaundice
24. MRI after one year , patient is presenting by itching without jaundice
36. 10 days after repair with stent 7 french splinting
the anastomosis
37. Lessons to be learnedLessons to be learned
The most common injury is excision of aThe most common injury is excision of a
segment of the CBD ( the CBD is usuallysegment of the CBD ( the CBD is usually
narrow enough to be recognized as thenarrow enough to be recognized as the
cystic duct) with short cystic or sessile gallcystic duct) with short cystic or sessile gall
bladder.bladder.
Direct anastomosis is almost alwaysDirect anastomosis is almost always
feasible with no tension on suture line iffeasible with no tension on suture line if
adequate mobilization of the distal segmentadequate mobilization of the distal segment
was done with adequate Khorization of thewas done with adequate Khorization of the
duodenumduodenum
38. Lessons to be learnedLessons to be learned
• The distal segment is ensheathed in a special sheathThe distal segment is ensheathed in a special sheath
which separates it from pancreatic tissue with loosewhich separates it from pancreatic tissue with loose
areolar tissue separating it from that sheath, andareolar tissue separating it from that sheath, and
dissection in this plane is very easy without endangeringdissection in this plane is very easy without endangering
the blood supply of the duct. There are no blood vesselsthe blood supply of the duct. There are no blood vessels
transecting that loose areolar tissue which suggests thattransecting that loose areolar tissue which suggests that
the blood supply of that segment is intramural and is notthe blood supply of that segment is intramural and is not
segmental.segmental.
• This is contrary to the proximal segment where theThis is contrary to the proximal segment where the
presence of two Terbelanche vessels running along thepresence of two Terbelanche vessels running along the
lateral borders of the CBD suggests segmental bloodlateral borders of the CBD suggests segmental blood
supply ( a point for further research)supply ( a point for further research)
39. Lessons to be learnedLessons to be learned
The sooner the surgeon gets into theThe sooner the surgeon gets into the
field the easier and better was thefield the easier and better was the
dissection of both the proximal and distaldissection of both the proximal and distal
parts of the biliary tree. Waiting for 6parts of the biliary tree. Waiting for 6
weeks is no more accepted as a policy.weeks is no more accepted as a policy.
The T tube should be inserted from aThe T tube should be inserted from a
separate incision in the distal part of theseparate incision in the distal part of the
CBD with only part of the horizontal limbCBD with only part of the horizontal limb
stenting the anastomosisstenting the anastomosis
40. Lessons to be learnedLessons to be learned
The anastomosis is done using only fourThe anastomosis is done using only four
sutures of four zero vicryl to be tighten aftersutures of four zero vicryl to be tighten after
inserting the t tube in the distal part andinserting the t tube in the distal part and
directing the stent into the right duct in most ofdirecting the stent into the right duct in most of
the times.the times.
The T tube is not necessarily be made ofThe T tube is not necessarily be made of
silicone, a latex tube will do.silicone, a latex tube will do.
The Stay of three months does not lookThe Stay of three months does not look
mandatory however; further cases are neededmandatory however; further cases are needed
to make this clearto make this clear
41. Lessons to be learnedLessons to be learned
A t tube cholangiography can easilyA t tube cholangiography can easily
demonstrate the adequacy of the healingdemonstrate the adequacy of the healing
before extracting a t tube stenting suchbefore extracting a t tube stenting such
anastomosis.anastomosis.
A plastic stent can be used if T tubes areA plastic stent can be used if T tubes are
difficult to usedifficult to use
Low molecular weight heparin prophylaxisLow molecular weight heparin prophylaxis
is mandatory because of the manipulationis mandatory because of the manipulation
of the area of the IVC to avoid massiveof the area of the IVC to avoid massive
pulmonary embolism.pulmonary embolism.
