Hepaticojejunostomy: Indications and Surgical Technique

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Executive Summary

Hepaticojejunostomy (HJ) is a time-honored and durable reconstructive procedure essential for hepatobiliary surgery. While relatively rare in general surgical practice, its application has increased due to the prevalence of bile duct injuries associated with laparoscopic cholecystectomy. Success rates in centers of excellence currently exceed 90% in long-term follow-up, attributed to advancements in fine absorbable sutures, meticulous surgical technique, and precise preoperative anatomical mapping. The procedure’s success relies on achieving a tension-free, mucosa-to-mucosa anastomosis, supported by a thorough understanding of the biliary "road map" and intraoperative flexibility to accommodate anatomical variants.

Clinical Indications

The necessity for hepaticojejunostomy arises from both benign and malignant conditions, as well as iatrogenic trauma.

Benign Conditions and Trauma

  • Iatrogenic Bile Duct Injuries: Currently the most frequent indication, often resulting from laparoscopic cholecystectomy.

  • Biliary Fibrosis: Often produced by chronic pancreatitis.

  • Trauma: Penetrating trauma of the porta hepatis or iatrogenic trauma from other procedures such as gastrectomy, liver transplantation, portal decompressive procedures, and pancreatic or hepatic resections.

  • Congenital/Structural Issues: Choledochal cyst resections.

  • Recurrent Strictures: Previous bilioenteric operations that resulted in subsequent stricture formation.

Malignant Conditions

  • Primary Tumors: Cholangiocarcinomas.

  • Infiltrative Malignancy: Carcinomas of the gallbladder infiltrating the common bile duct (CBD) or hepatic ducts.

  • Palliative Care: Used as a final step in resective procedures or as a palliative attempt to relieve jaundice in unresectable cases.

Preoperative Assessment and "Road Mapping"

A definitive "road map" of the biliary tree is required before reconstruction. The choice of imaging depends on the suspected location of the stricture or tumor:

  • High (Proximal) Stenoses: Best studied via percutaneous transhepatic cholangiography (PTC).

  • Low (Distal) Stenoses: Best studied via endoscopic retrograde cholangiography (ERC).

  • Non-Invasive Alternatives: Magnetic resonance cholangiography is utilized for patients with contrast allergies, though PTC and ERC are preferred for their higher resolution.

  • Complementary Studies: Computed tomography (CT) and ultrasonography are used to clarify tumor extension or document the presence of a biloma.

Anatomical Considerations of the Porta Hepatis

Successful HJ requires a precise understanding of the anatomical arrangement of the porta hepatis:

  • Bile Duct: Typically travels on the patient’s right side and is the most anterior structure entering the liver.

  • Hepatic Duct (HD) Division: Above the cystic duct take-off, the common hepatic duct divides into the right and left HD. The right HD has a short extrahepatic course; the left HD extends approximately three centimeters before entering the umbilical fissure.

  • Hepatic Artery: Located on the left side of the porta hepatis, becoming posterior to the CBD and anterior to the portal vein high in the liver hilum.

  • Portal Vein: The largest and most posterior structure in the hepatoduodenal ligament.

  • Surgical Advantage: This arrangement provides free anterior access, allowing for the unencumbered ascent and descent of the jejunal loop or Roux-en-Y limb.

Surgical Technique and Methodology

1. Exposure and Localization

  • Malignancy Protocol: The bile duct is doubly ligated proximally, and the gallbladder is retracted laterally.

  • Identifying Injuries: For laparoscopic injuries, surgeons locate the stenosing clip or ligature near the confluence.

  • Localization Aids: Transhepatic stents can assist in localizing structures. If doubt exists, a fine needle (18G-20G) can be inserted into a dilated structure to confirm the presence of bile.

  • Hilar Plate Incision: To expose the hepatic ducts (particularly the left HD), the hilar plate is incised and elevated, providing access to the entire anterior portion of the ducts.

2. Jejunal Limb Preparation

  • Selection: A proximal jejunal loop is selected that reaches the right upper quadrant without tension.

  • Roux-en-Y Limb: A 50-cm Roux limb is tailored.

  • Route: The limb is passed in a retrocolic fashion through the transverse mesocolon, typically to the right of the middle colic vessels—an area generally free of vascular structures.

  • Fixation: The mesocolon is closed around the jejunum with interrupted 3-0 silk stitches to prevent internal hernias.

3. Anastomotic Construction

The procedure prioritizes a tension-free, meticulous mucosa-to-mucosa anastomosis.

Step

Technical Detail

Bile Duct Preparation

The duct opening is expanded bilaterally, with emphasis on the left, to create a wider side-to-side anastomosis.

Jejunal Incision

The jejunal opening is initially smaller than the duct defect, as it enlarges during the creation of the anastomosis.

Suture Type

Interrupted absorbable sutures, size 4-0 or 5-0.

Blumgart Technique

Corner stitches are placed first at the left side. Half of the anterior row is constructed first to lift the duct, facilitating the posterior row.

Suture Management

Use of different suture colors and a spring keeper to maintain mild tension and organize the field.

Tying Protocol

Posterior sutures are tied starting from the patient's right side with knots inside the anastomosis to enhance mucosal approximation.

Strain Relief

3-0 silk stitches are placed between the jejunal seromuscular layer and the liver capsule to relieve tension on the anastomosis.

4. Special Technical Considerations

  • Benign Strictures: A defect is created in the anterior part of the duct and extended onto the left HD.

  • Separated Hepatic Ducts: If the right and left HDs cannot be brought together (common in resected hilar cholangiocarcinoma), two separate anastomoses are required using the same meticulous technique.

  • Biliary Stenting: While not routine, transhepatic stents can assist in intraoperative identification, postoperative patency assessment (via contrast studies), and manometric studies for outpatient management.

  • End-to-Side Alternative: Used in cases of long-standing biliary obstruction with extensive dilatation where the biliary stump is well-perfused and pliable.

Postoperative Completion

  • Drainage: A soft silastic drain is placed in the subhepatic space near the anastomosis.

  • Final Steps: The intestinal continuity is completed via standard end-to-side or side-to-side (sutured or stapled) anastomosis. The abdomen is closed following thorough irrigation.