A New Instrument for Inserting a U Tube Terrence W. Tatarchuk, MD, Cadillac, Michigan Thomas T. White, MD, FACS, Seattle, Washington
We have found that transhepatic splints are difficult to place in connection with the treatment of benign and malignant strictures of the upper hepatic duct and bifurcation. Rodney Smith [I] first proposed combining transhepatic intubation with hepaticojejunostomy for very high strictures of the hepatic ducts using a straight red rubber catheter in 1964 [2,2]. He pushed a Randall forceps upwards through the extra- and intrahepatic ducts, perforated the surface of the liver from within, then pulled a long fenestrated straight rubber tube down across the anastomosis. Saypol and Kurian [3] used essentially the same technic for strictures, except they brought both ends of the red rubber tube out to the surface. Their notion was that the catheter would be easier to change after it became plugged with debris. Terblanche and his associates [4,5] later extended the use of U tubes to carcinomas around the bifurcation of the hepatic duct in ten patients. This technic differed from that of Smith [I] and Saypol and Kurian [3] in that a Bakes dilator was passed from below, upward through the surface of the liver, instead of a Randall forceps. The malignant stricture was first gradually dilated up to 4 to 5 mm in diameter. A heavy suture was then attached to the Bakes dilator as it protruded through the surface of the liver, brought back through the common bile duct, and then attached to the catheter. The U tube, a 16 From the Department of Surgery, University of Washington, Seattle, Washington. Reprint requests should be addressed to Thomas T. White, MD, Department of Surgery RF-25, University of Washington, Seattle, Washington 98195.
volume
137, March 1879
gauge Meredith thoracic catheter, could then be pulled up through the bile ducts to the surface of the liver. The two ends of the catheter were then brought out through the abdominal wall to the surface. We have found that the heavy ligature used in Terblanche’s technic for inserting a U tube tends to cut the liver parenchyma, with the result that there is considerable intrahepatic damage and bleeding. For this reason we have attached perforated Silastic@ tubing directly to the bulb of the dilator and withdrawn the tubing through the liver to the extrahepatic bile ducts. Since there is a tendency for the Silastic tubing to slip off the dilator as it is passed back through the liver towards the common bile duct, we have devised a new instrument which eliminates the problem of slippage. This instrument has a circumferential groove in the tip of the dilator as well as a small hole. (Figure 1.) A ligature can be passed around the tubing to secure it in place, or a suture can be passed through the tubing and the hole. This simple modification eliminates unnecessary instrumentation of the hepatic ducts and the chance of creating multiple tracts in the liver as well as the sawing and cutting action of the heavy ligature upon the liver parenchyma. Summary
A new instrument for through malignant and consists of a 3 mm Bakes cumferential groove and tip.
the placement of U tubes benign biliary strictures dilator modified by a cira small hole through its
425
Tatarchuk and White
Figure 7. Left, our modification of the 3 mm Bakes dilator. Right, the Bakes dilator with the Silastk tubing sutwed in place.
References 1. Smith R: Hepaticojejunostomy with transhepatic intubation. A technique for very high strictures of the hepatic ducts. Br J Surg51: 186, 1964. 2. Knight M, Smith R: Repair of severed or strictured bile ducts, p 361. Operative Surgery (Rob C, Smith R. gen eds; Dudley H, Rob C, Smith R, consultant eds). London, Butterworths,
426
1977. 3. Saypol GM, Kurian G: A technique of repair of stricture of the bile duct. Surg Gynecol Obsfet 128: 1071, 1969. 4. Terblanche J, Saunders SJ, Louw JH: Prolonged palliation in carcinoma of the main hepatic duct junction. Surgery 71: 720, 1972. 5. Terblanche J: Is carcinoma of the main hepatic duct junction an indication for liver transplantation or palliative surgery? A plea for the U-tube palliative procedure. Surgery 79: 127, 1976.
The American Journal of Surgery
We have found that transhepatic splints are difficult to place in connection with the treatment of benign and malignant strictures of the upper hepatic duct and bifurcation. Rodney Smith [I] first proposed combining transhepatic intubation with hepaticojejunostomy for very high strictures of the hepatic ducts using a straight red rubber catheter in 1964 [2,2]. He pushed a Randall forceps upwards through the extra- and intrahepatic ducts, perforated the surface of the liver from within, then pulled a long fenestrated straight rubber tube down across the anastomosis. Saypol and Kurian [3] used essentially the same technic for strictures, except they brought both ends of the red rubber tube out to the surface. Their notion was that the catheter would be easier to change after it became plugged with debris. Terblanche and his associates [4,5] later extended the use of U tubes to carcinomas around the bifurcation of the hepatic duct in ten patients. This technic differed from that of Smith [I] and Saypol and Kurian [3] in that a Bakes dilator was passed from below, upward through the surface of the liver, instead of a Randall forceps. The malignant stricture was first gradually dilated up to 4 to 5 mm in diameter. A heavy suture was then attached to the Bakes dilator as it protruded through the surface of the liver, brought back through the common bile duct, and then attached to the catheter. The U tube, a 16 From the Department of Surgery, University of Washington, Seattle, Washington. Reprint requests should be addressed to Thomas T. White, MD, Department of Surgery RF-25, University of Washington, Seattle, Washington 98195.
volume
137, March 1879
gauge Meredith thoracic catheter, could then be pulled up through the bile ducts to the surface of the liver. The two ends of the catheter were then brought out through the abdominal wall to the surface. We have found that the heavy ligature used in Terblanche’s technic for inserting a U tube tends to cut the liver parenchyma, with the result that there is considerable intrahepatic damage and bleeding. For this reason we have attached perforated Silastic@ tubing directly to the bulb of the dilator and withdrawn the tubing through the liver to the extrahepatic bile ducts. Since there is a tendency for the Silastic tubing to slip off the dilator as it is passed back through the liver towards the common bile duct, we have devised a new instrument which eliminates the problem of slippage. This instrument has a circumferential groove in the tip of the dilator as well as a small hole. (Figure 1.) A ligature can be passed around the tubing to secure it in place, or a suture can be passed through the tubing and the hole. This simple modification eliminates unnecessary instrumentation of the hepatic ducts and the chance of creating multiple tracts in the liver as well as the sawing and cutting action of the heavy ligature upon the liver parenchyma. Summary
A new instrument for through malignant and consists of a 3 mm Bakes cumferential groove and tip.
the placement of U tubes benign biliary strictures dilator modified by a cira small hole through its
425
Tatarchuk and White
Figure 7. Left, our modification of the 3 mm Bakes dilator. Right, the Bakes dilator with the Silastk tubing sutwed in place.
References 1. Smith R: Hepaticojejunostomy with transhepatic intubation. A technique for very high strictures of the hepatic ducts. Br J Surg51: 186, 1964. 2. Knight M, Smith R: Repair of severed or strictured bile ducts, p 361. Operative Surgery (Rob C, Smith R. gen eds; Dudley H, Rob C, Smith R, consultant eds). London, Butterworths,
426
1977. 3. Saypol GM, Kurian G: A technique of repair of stricture of the bile duct. Surg Gynecol Obsfet 128: 1071, 1969. 4. Terblanche J, Saunders SJ, Louw JH: Prolonged palliation in carcinoma of the main hepatic duct junction. Surgery 71: 720, 1972. 5. Terblanche J: Is carcinoma of the main hepatic duct junction an indication for liver transplantation or palliative surgery? A plea for the U-tube palliative procedure. Surgery 79: 127, 1976.
The American Journal of Surgery
