The preferred repair for most bile duct injuries is biliary-enteric anastomosis, most commonly with Roux-en-Y hepatico- or choledocho-jejunostomy. In some instances, however, other repairs are preferred.
Nonthermal injuries that involve less than 50% of the duct circumference may be considered for primary repair over a T tube. Injuries caused by electrocautery or > 50% of the duct circumference require major biliary reconstruction.
Defects shorter than 1 cm and distal to the hilum and hepatic duct bifurcation may be repaired with end-to-end choledocho-choledochostomy if adequate mobilization can be performed to allow a tension-free anastomosis. A transanastomotic T tube should be placed through a separate vertical choledochotomy.
Distal bile duct injuries can be reimplanted in the duodenum (choledocho-duodenostomy) if a tension-free repair can be achieved with a Kocher maneuver. This allows for future endoscopic access to the biliary tree but is associated with a higher risk of anastomotic leak than a Roux-en-Y choledocho-jejunal anastomosis.
The key steps of a hepatico- or choledocho-enteric anastomosis:
Carefully dissect the porta hepatis. This can be assisted by following drain tracts, identifying previously placed clips, or using needle aspiration of the porta to delineate biliary from vascular structures.
Drop the hilar plate carefully, dissecting in an avascular plane immediately anterior to the bifurcation of the hepatic ducts. This allows for delineation and exposure of the extrahepatic portion of the left hepatic duct as well.
Dissect back to the healthy bile duct. Care should be taken to minimize risk of vascular compromise of the anastomosis. If there is concomitant vascular injury (most commonly right hepatic artery injury), extension of the anastomosis onto the left hepatic duct with a Hepp-Couinaud technique should be considered to decrease the risk of late biliary stricture.
Perform an end-to-side mucosa-to-mucosa anastomosis (or side-to-side if extending onto the left hepatic duct) of the bile duct to the Roux-en-Y jejunal limb. A fine absorbable monofilament suture, most commonly 5-0 polydioxanone (PDS), may be used.
Place a PTC drain, if one is used, across the anastomosis.
Then create a jejuno-jejunostomy approximately 50 cm downstream of the biliary enteric anastomosis to complete the Roux-en-Y reconstruction.
Educational aid only. Verify every dose, indication, and guideline against current institutional protocol. This is not a substitute for clinical judgment.
