Common operative problems in hepatobiliary surgery.

r Complications of General Surgery

0039-6109/91 $0.00

+ .20

Common Operative Problems in Hepatobiliary Surgery William]. Schirmer, MD,* Ricardo L. Rossi, MD,t Kevin S. Hughes, MD,+]. Lawrence Munson, MD,§ and]ohn W. Braasch, MD, PhDl1

Knowledge about hepatobiliary surgery continues to evolve. Mortality rates for major resection of the liver have fallen dramatically. 12. 21. 22. 29. 52. 56. 60.62.64 Much of this progress can be credited to a better understanding of hepatic anatomy and refinements in surgical techniques. During the same time frame, fiberoptic technology has revolutionized the diagnosis and management of disorders of the biliary tract. The most recent technologic advancement has been laparoscopic cholecystectomy. Without the benefit of controlled studies, many surgeons consider laparoscopic cholecystectomy the procedure of choice for removing the gallbladder. Science has taken a back seat to the demands of the consumer. For these newer techniques and technologies to be applied with greater insight and safety, surgeons must continue to develop and refine their expertise in hepatobiliary procedures. Safe and successful surgery on the liver and bile ducts requires detailed knowledge of anatomy and physiology, technical competence, and a good understanding of the underlying disease and therapeutic alternatives. Most intraoperative and postoperative complications can be traced to some violation of these basic principles and are therefore preventable. PATIENT SELECTION, PREPARATION, AND EVALUATION Recovery after an operation that was well executed is determined primarily by the patient's overall health. To limit further morbidity and From the Department of General Surgery, LaiIey Clinic Medical Center, Burlington, Massachusetts

*Formerly,

Fellow in Gastrointestinal Surgery; Currently, Assistant Professor, Department of Surgery, The Ohio State University College of Medicine, Columbus, Ohio tChairman; and Assistant Clinical Professor of Surgery, Harvard Medical School, Boston, Massachusetts *StaII'; and Clinical Instructor in Surgery, Harvard Medical School, Boston, Massachusetts §Staff IISenior Consultant; and Assistant Clinical Professor of Surgery, Harvard Medical School, Boston, Massachusetts

Surgical Clinics of North America-Vol. 71, No.6, December 1991

1363

f 1364

WILLIAM

J.

SCHIRMER ET AL.

mortality rates, attention must be given to the selection of patients and preoperative preparation. Advanced age, malignancy, weight loss, malnutrition, cirrhosis, renal failure, and jaundice correlate with a poorer outcome. H . 47. 59 With advanced age, the likelihood of cardiovascular, pulmonary, and renal insufficiency increases. We hesitate to apply cutoffs based on age and prefer patient selection based on risk factors. Unfortunately, no reliable formulas or methods exist that predict outcome. Some groupS23. 50 have evaluated physiologic scoring systems, such as the acute physiology and chronic health evaluation (APACHE) II score, which takes into consideration several variables, including age, preexisting disease, and acute physiologic status. Although a reliable predictor of major complications for a certain subset of procedures, these methods often serve only to reinforce clinical judgment. Malnutrition and weight loss increase the risk for complications after major gastrointestinal surgery. 7. 38 The question remains whether we can appreciably decrease the operative risk in these patients by attempting to correct deficiencies before operation with a course of nutritional supplementation. A prospective Veterans Affairs Cooperative study attempted to answer this question (Buzby GP, personal communication, 1991). Patients who were to undergo major gastrointestinal surgical procedures were randomly grouped; one group received total parenteral nutrition for 7 to 15 days before operation and 3 days after operation, and a control group received no total parenteral nutrition. No difference in morbidity or mortality rates could be demonstrated except in a small subset of the most severely malnourished patients. These individuals usually had a serum albumin level of less than 30 gm/L or had experienced a 15% or greater reduction in body weight or both. Complicated nutritional assessments are not necessary to remind the surgeon that these patients may not do well. In the more marginally malnourished patients, the Veterans Affairs study revealed an increase in infectious complications in patients who received total parenteral nutrition compared with patients who did not. A possible explanation for this is an increased incidence of catheter-related sepsis. The inherent risks of the temporizing measures therefore must be considered, including complications associated with central venous catheters. Routine use of total parenteral nutrition before operation, except in patients with extreme malnutrition, should be discouraged because it adds time, expense, and risk without clear benefit to outcome. Similarly, routine preoperative biliary decompression in the jaundiced patient has not lived up to earlier expectations. 10, 18, 30, 41, 48 We prefer endoscopic to transhepatic biliary decompression and use it before operation in deeply jaundiced patients who also have evidence of active hepatocellular injury as evidenced by elevated serum levels of hepatic transaminase or in patients with evidence of diminished hepatocellular reserve. We also consider the use of preoperative stents in patients with reversible renal failure and in some patients with biliary sepsis. Cirrhosis is not uncommon in patients with hepatobiliary disorders. The immediate and long-term risks of hepatectomy must be considered before a decision is made regarding resection. 20,33,39,63 Bleeding is increased because of portal hypertension, hepatic fibrosis, and the often coexistent

COMMON OPERATIVE PROBLEMS IN HEPATOBILIARY SURGERY

1365

coagulopathy. Many of these patients are chronically malnourished. The patient with cirrhosis not only has a decreased functional reserve but also has diminished regenerative capability. Finally, the cirrhotic liver is relatively intolerant of the chemotherapy and radiation therapy that may be considered necessary adjuvants to operation. The risks attending all biliary procedures, including cholecystectomy, are greatly increased. 54 At times, a portosystemic shunt should precede major dissection of the porta hepatis to avoid the possibility of uncontrollable hemorrhage. 55 Preoperative evaluation of patients with potential surgical hepatobiliary disorders should be directed toward determining a likely diagnosis and an estimation of the extent of disease. Preoperative tissue diagnosis of hepatic or biliary tumors is not always possible and is often unadvisable and unnecessary. In the presence of strong presumptive evidence of a resectable hepatic tumor, biopsy is best deferred until laparotomy to avoid the possibility of rupture or dissemination of a tumor or hemorrhage. Ultimately, these patients often require laparotomy to establish a diagnosis and to attempt resection or effect definitive biliary decompression. Frozensection study of operative material is not reliable in excluding biliary carcinoma or in differentiating between liver adenoma and a low-grade hepatoma. Therefore, clinical, radiologic, and operative information often determines the therapeutic approach. For hepatic lesions, some combination of roentgenography of the chest, ultrasonography, and angiography usually provides the information necessary to make a preoperative determination of resectability. Hepatic arteriography also gives valuable information regarding the frequent variations in hepatic arterial supply. The venous phase after superior mesenteric or splenic arterial injection may demonstrate involvement of the portal vein with tumor. On rare occasions, inferior vena cavography provides additional valuable information regarding the posterior extent of tumor. It may not always be possible to distinguish compression from invasion on the basis of these studies; therefore, they should serve as aids in planning the operative approach rather than definitive indicators of resectability. Biliary tract disease can usually be assessed adequately by a combination of ultrasonography, endoscopic retrograde cholangiopancreatography, and percutaneous transhepatic cholangiography. Hepatic arteriography should also be obtained for lesions at or near the hepatic bifurcation because of the possibility that partial hepatectomy may be required in addition to resection of the bile duct. The critical information required for a surgical approach to obstructing bile duct lesions is the proximal extent of the obstruction. This information can be obtained satisfactorily with ultrasonography and percutaneous transhepatic cholangiography. Endoscopic retrograde studies are preferred in distal obstruction or when ductal calculous disease is suspected or must be ruled out. In this latter setting, endoscopy may prove therapeutic as well as diagnostic. Endoscopic retrograde studies for proximal obstruction are useful only when partial obstruction is present. The routine placement of biliary stents should be avoided when operation is planned in the near future. The benefits gained from lowering serum bilirubin levels preoperatively have not been proved; the stent provides an avenue and nidus for bacterial contamination, and it can increase the

1366

WILLIAM

J.

SCHIRMER ET AL.

difficulty in identifYing and suturing a proximal bile duct, especially when intrahepatic anastomoses are performed. To optimize results, a team approach must be adopted. The anesthesiologist must be prepared to deal with massive blood loss, temporary vena caval interruption, hypothermia, and acute hepatic dysfunction. Competent nurses and technicians ensure proper functioning of equipment (i.e., cellsaving devices). SURGICAL ANATOMY OF LIvER AND BILIARY SYSTEM The most important complications of liver resection are hemorrhage, leakage of bile, and infection. The first step toward uncomplicated liver resection is an awareness of the vascular anatomy. The complications of intraoperative blood loss and attendant massive transfusion include hypotension, air emboli, transfusion reaction, transmission of viral infection, pulmonary dysfunction, renal dysfunction, increased incidence of infection, and possibly tumor recurrence. 58 A bloody field compromises exposure and makes bile duct injury or biliary fistulas more likely. Large hemostatic sutures produce large pieces of necrotic liver. A recipe for abscess is intraoperative hypotension and massive transfusion mixed with hematoma, leakage of bile, and necrotic tissue. Surgeons in general are less familiar with the intricacies of intrahepatic architecture than they are with any other abdominal organ. Couinaud9 and Goldsmith and Woodburue 17 outlined functional segmentation of the liver based on the distribution of portal pedicles and the location of the hepatic veins. Knowledge of the location of these major veins permits the surgeon to maneuver within the liver substance with greater safety and assurance. Unfortunately, the nomenclature of liver anatomy has yet to be standardized. The French,9 pioneers in the field of hepatic and biliary surgery, consider the right and left hepatic lobes to be divided by the ligamentum teres. Therefore, in their descriptions, "right hepatectomy" is removal of the liver to the right of the ligamentum teres. By Anglo-Saxon convention, such a resection would be considered extended right hepatectomy or right hepatic trisegmentectomy. In general, we use the AngloSaxon descriptions that separate the right and left lobes of the liver by the distribution of portal pedicles. A line drawn from the left edge of the gallbladder fossa to the suprahepatic cava (the median fissure or lobar plane) is the dividing line between right and left lobes. Segmental Anatomy The convention rapidly gaining acceptance is division of the liver into eight distinct functional segments based on the distribution of the portal venous pedicles and the location of the hepatic veins. The left branch of the portal vein supplies the left lobe and the right branch, the right lobe. The caudate lobe receives branches from both the right and the left branches of the portal vein. Each major branch bifurcates once again, thereby dividing the liver into four functional sectors. Between each sector course the three major hepatic veins. Further branching of the portal venous supply within each sector forms the final eight segments.


1367

Segment I is the caudate lobe. Its blood supply comes from both the right and left portal veins and arteries. The venous drainage empties directly into the inferior vena cava. Obstruction of the major hepatic veins leaves the smaller branches of the caudate lobe as the only route for hepatic venous outflow in the Budd-Chiari syndrome. Hypertrophy of the caudate lobe may in turn lead to vena caval obstruction that becomes an important consideration in surgical therapy for these patients. The left lobe is divided into three segments. Segment II posteriorly and segment III anteriorly combine to form what is traditionally referred to as the left lateral segment. The medial portion of the left lobe is segment IV. The right lobe is divided into two sectors and four segments. Segment V is situated anteriorly, immediately to the right of the gallbladder fossa. Segment VI is situated on the right lateral and inferior aspect of the liver bounded posteriorly by a plane passing through the hilum. Segment VII is located superiorly and posteriorly, lying to the right of the course of the right hepatic vein. Segment VIII is situated on the superior surface between the right and middle hepatic veins and just superior to segment V. Written descriptions of complex anatomic arrangements usually fall short of their intended goal, which is to educate and inform the reader. The surgeon is referred to any of the excellent detailed descriptions 2 , 14 of hepatic anatomy. Hepatic Veins The hepatic veins form the dividing lines between segments and sectors. The middle hepatic vein divides the liver into right and left halves. Its course can be estimated by a line drawn from the left side of the suprahepatic vena cava to the left edge of the gallbladder fossa. The termination of the middle hepatic vein will be into the left hepatic vein in about 85% of patients but may enter the vena cava independently or even be fused to the right hepatic vein to form a common trunk. The left hepatic vein courses through the substance of what is traditionally referred to as the left lateral segment but by current conventions is the plane of fusion between segments II and III. The right hepatic vein follows a curved course from between segments V and VI inferiorly to segments VIII and VII superiorly. Its location can be estimated by a line running three fingerbreadths anterior and parallel to the right lateral edge of the liver. The preceding descriptions of the course of hepatic segments and veins pertain to normal liver anatomy. Within the bounds of normal are several variants. Also, pathologic processes distort normal anatomy. Intraoperative ultrasonography solves the problems of variant and abnormal anatomy. The course of veins can be visualized before beginning parenchymatous dissection. The size and extent of intrahepatic tumors can be determined and the bounds of resection planned. Routine use of intraoperative ultrasonography is not essential but will increase the surgeon's facility with this technique, which may prove beneficial in difficult situations. Hepatic Arteries The arterial supply of the liver represents only 25% of the actual flow but carries 50% of its oxygen supply. Right and left hepatic arteries branching from a common hepatic artery is the typical arrangement. The

1368

WILLIAM ]. SCHIRMER ET AL.

most frequent variations are a right hepatic artery arising from the superior mesenteric artery and a branch to the left coming from the left gastric artery. When the hepatic arteries bifurcate from a common trunk, the point of bifurcation may be anywhere from the celiac axis to the hepatic hilum. Because of the frequent variations, we prefer hepatic angiography before elective hepatic resection. At times, it may be necessary to operate on the liver without the benefit of preoperative angiography. Careful dissection of the porta hepatis, usually superior and to the left of the common bile duct, will reveal the hepatic artery. The porta hepatis should be palpated between thumb and finger. A pulsation perceived posterior or to the right of the portal vein is most likely from a replaced right hepatic artery arising from the superior mesenteric artery. The fingers placed behind the porta hepatis not only locate pulsations but serve to deliver the vessels toward the operator, facilitating rapid and safe dissection. Bile Ducts Within the liver, the hepatic arterial branches, portal venous branches, and bile ducts (the portal triad) travel together within a connective tissue sheath. The left hepatic duct drains segments II, III, and IV. The right hepatic duct drains segments V, VI, VII, and VIII. The junction of the two main ducts takes place at the hepatic hilum within an invagination of Glisson's capsule or the hilar plate. Drainage from the caudate lobe is variable and may be to either or both of the main ducts or directly into the bifurcation. Failure to incorporate caudate ducts into the enteric segment during bilioenteric reconstruction is a cause of leakage of bile and cholangitis. Some authors 35• 42 believe that failure to resect the caudate lobe during resection of the hepatic bifurcation for tumor is a common cause of recurrence, pointing out that tumor extension is frequent but nearly impossible to rule out either clinically or by frozen section analysis. The typical anatomic arrangement in which the hepatic bifurcation is formed by the right and left hepatic ducts draining their respective sides of the liver independently is present in only 60% of patients. Not infrequently, one or more of the major segmental ducts from the right empty into the left hepatic duct just before the bifurcation. These ducts must be recognized and incorporated into the reconstruction to prevent them from being ligated or left out of the anastomosis. Preoperative or intraoperative cholangiography is a helpful aid in preventing these mishaps. The extrahepatic bile ducts are formed by the confluence of the right and left hepatic ducts, the cystic duct, and the common hepatic and common bile ducts. The common duct is anterior to the portal vein and to the right and inferior to the common hepatic artery. The distal common bile duct courses posteriorly to the supraduodenal vessels and through the pancreatic head. The blood supply of the extrahepatic ducts is through a pair of vessels running in an axial orientation along the lateral borders of the duct. 43 These so-called 3 o'clock and 9 o'clock arteries are fed by the right hepatic and cystic arteries from above the hepatic artery in midposition and the gastroduodenal and retroduodenal arteries below. Dissection and mobilization around the duct are kept to the minimum required to provide


1369

for a mucosa-to-mucosa anastomosis to avoid compromising the blood supply to the ductal margin. The gallbladder is located on the undersurface of the liver. Its blood supply is by means of the cystic artery, a branch of the right hepatic artery. Anomalies of the gallbladder and its ductal drainage are so common that they must be considered as variations of normal anatomy. The cystic duct may enter directly into, travel parallel to, or spiral around the common hepatic duct. The gallbladder may be connected by small ducts directly to the right intrahepatic ducts at the gallbladder fossa. It may drain into the right or even the left hepatic duct rather than into the common hepatic duct. Rarely, bilobed, septated, or duplicated gallbladders are encountered. The surgeon must make no assumptions. The attitude should be that each dissection will be carried out to determine which variant of normal anatomy is present in each patient. INTRAOPERATIVE COMPLICATIONS OF HEPATIC RESECTION The incision, assessment of resectability, and conduct of dissection must be individualized. The procedure must be tailored to the nature and location of tumors. Benign cysts, hemangiomas,. and tumors may be removed by simple enucleation. Peripherally located lesions may require nothing more than wedge resection. Segmental resection based on previously described intrahepatic portal divisions permits the resection to be confined to the minimum amount of parenchyma necessary to effect removal of the tumor and at the same time preserve maximal liver. Formal lobar resections are often preferable when tumors are deep and more centrally located and span multiple segments. Combining principles of lobar and segmental resection permits the experienced hepatic surgeon to extend the bounds of resection when tumors are large and centrally located and cross the median fissure. Exposure, Mobilization, and Assessment of Resectability The need for wide exposure cannot be overemphaSized. With the patient in the supine position and the right arm either extended or elevated over the face with a lift, the field is prepared widely for laparotomy and possible extension to the sternum or right chest. A bilateral subcostal incision with midline extension to the xiphoid process is preferred for most resections. The rightward subcostal aspect can be extended well into the flank to enable an unencumbered view and access to the retrohepatic area. When control of the suprahepatic vena cava is necessary, median sternotomy with opening of the pericardium is the most direct approach. With the advent of self-retaining retractors, a right thoracic extension is rarely necessary but may be useful when tumors are large and need to be displaced upward to expose the hepatic hilum. The assessment of resectability begins well before the operation and continues throughout the operative procedure. At times, it is not clear whether a tumor is resectable until the time the specimen is removed. The abdomen should be explored thoroughly, particularly in the presence of

1370

WILLIAM

J.

SCHIRMER ET AL.

metastatic tumors from a gastrointestinal or unknown primary lesion. Hepatic hilar lymph nodes are sampled. Extrahepatic tumor extension will most often preclude resection. The extent of disease within the liver and the general condition of the liver must be ascertained. Evidence of cirrhosis may make the surgeon review a decision to perform major resection. As a rule, bimanual palpation of the right and left sides of the liver will detect tumors from 1 cm in diameter upward. Intraoperative ultrasonography may be able to detect even smaller lesions, but in general, we have not found this technique clinically valuable. Complete assessment of resectability will nearly always require some degree of mobilization of the liver. The ligamentum teres should be divided. The falciform ligament is incised toward the inferior vena cava. The triangular ligaments should be incised, taking care to avoid injury to phrenic veins and the superior border of the left hepatic vein. Dividing the gastrohepatic omentum up to the suprahepatic vena cava enables the left side of the liver to be rotated. Preoperative angiography should warn of a possible aberrant location of the left hepatic artery, which may be found in the gastrohepatic omentum. Incision of the peritoneal reflections attached to the right side of the liver permits its preliminary mobilization. This dissection begins at the right corner of the right triangular (or coronary) ligament and proceeds medially toward the inferior vena cava. The peritoneal reflection from the duodenum to the diaphragm is incised at this point. Care must be taken to avoid injury to the right adrenal gland. This exposes the entire bare area of the diaphragm and enables the liver to be rotated to the left. The short venous channels between the caudate lobe and the inferior vena cava should be divided when further mobility is needed or when the decision has been made to proceed with formal right hepatectomy. The surgeon requires the help of a skilled assistant. The liver must be rolled anteriorly and to the left. Too little traction will compromise exposure, and too vigorous traction may result in avulsion of these fragile veins. The venous bridges can be exposed using a combination of sharp and blunt dissection. The vessels should be tied in continuity and cut. This dissection is carried out to the left side of the vena cava and superiorly to the insertion of the hepatic veins. Because these vessels are short, the distance between ties is limited; it is therefore easier to use a knife than scissors to divide the vessels. Vascular staples are avoided because they tend to fall off during further handling of the liver. Bleeding

Retrohepatic bleeding can be difficult to manage. The caudate venous branches are under traction and when cut tend to retract into the liver. Bleeding occurs when the veins are cut too close to a tie, when a staple falls off, or when traction is too vigorous. The initial temptation to get a better look at the bleeding site should be resisted. This would require rolling the liver upward even farther and may lead to a larger rent in the inferior vena cava or to avulsion of neighboring veins. The area should be packed, the liver rolled back to its normal position, and gentle pressure applied from the anterior liver surface toward the inferior vena cava.


1371

Difficulty with a posterior dissection should be anticipated when the tumors are large or when the liver is stiff. Bleeding problems can be avoided when these situations are recognized in advance. The incision should be enlarged to optimize exposure when needed. When bleeding occurs, the Pringle maneuver is helpful. The fingers of the left hand are passed behind the porta hepatis through the foramen of Winslow and hooked anteriorly against the gastrohepatic omentum. As a temporizing measure, the porta hepatis can simply be squeezed to occlude hepatic arterial and portal venous flow. When longer periods of occlusion are needed, some surgeons advocate placing a large vascular clamp across the entire porta hepatis. We prefer a looped Penrose drain placed around the porta hepatis, much as a vessel loop would be used to occlude a vessel. The loop can be tightened and released as needed, and we believe it may be less traumatic than a clamp. The combination of occluding hepatic inflow and the time it took to extend the incision and apply the Pringle maneuver may have been sufficient to limit bleeding to the point of control. The liver can be rolled back up, and with ample suction, the bleeding source is identified. When the bleeding is coming from the inferior vena cava and the rent can be exposed, it should be repaired with a vascular suture. When bleeding is excessive, it is likely that the damage is to a major hepatic vein or that there is a large rent in the inferior vena cava. The field should again be packed and the liver rolled back into place. The next maneuver should be to interrupt vena caval flow temporarily by passing tapes circumferentially around the vessel above and below the liver. The inferior tape should be placed above the right renal vein. The suprahepatic vena cava can occasionally be controlled with downward traction of the liver and a vascular clamp placed at the junction of the vena cava with the diaphragm. When the bleeding is at or near the junction of the major hepatic veins with the vena cava, it is best to enter the mediastinum and control the suprahepatic vena cava within the pericardium. Of course, the anesthesiologist must be made aware of the anticipated reduction in venous return and be prepared to handle it appropriately. We do not advocate routine preliminary control of the hepatic veins before parenchymatous transection. The short extrahepatic course of the right hepatic vein and the acute angle it often takes into the vena cava make its circumferential dissection dangerous. The bleeding problems outlined previously and the maneuvers needed to achieve control can often be avoided if the veins are controlled from within the liver substance. An exception to this general approach, in which preliminary division of the right hepatic vein may be attempted, is for tumors in the right lobe that overlie the vein near its junction with the inferior vena cava. In these patients, it may be particularly difficult to locate and control the right hepatic vein from within the liver without going through tumor itself or without compromising the margin of resection. Even in these patients, we will not persist with extrahepatic control unless the situation is optimal. A technique of total vascular exclusion may be required in such patients. Hilar Dissection The need for and extent of hilar dissection are determined by the disease present, the planned procedure, and the surgeon's individual

1372

WILLIAM

J.

SCHIRMER ET AL.

preference. Complications of hilar dissection include injury to any of the major ducts, arteries, and veins in the area. For centrally located lesions, hilar dissection is an essential part of determining resectability and removing the lesion. For more peripherally located lesions, the surgeon has the choice of achieving vascular control from within the liver, at the hilum, or proximal to the hilum with the Pringle maneuver. The approach is tailored to each patient. The Pringle maneuver is probably tolerated for periods of 45 to 60 minutes by the normal liver. Many livers are not normal, however. Complete interruption of venous drainage from the intestine may lead to bowel edema. On the other hand, with tumors lateralized to one side or another in which a simple enucleation or wedge resection is planned, the period of ischemia is usually less than 30 minutes, and the Pringle maneuver avoids the time and hazards of hilar dissection. The surgeon must keep in mind the frequent anatomic anomalies in this area and adhere to a policy of not ligating or dividing any structure until its precise nature is known with certainty. Because of the intimate proximity of ducts, arteries, and veins, it is often not possible to distinguish the three by simple inspection and palpation. Arterial pulsations may be transmitted to neighboring structures, making it easy to confuse arteries with ducts. A needle on a syringe is an extremely valuable tool before continuing dissection. Complete hilar dissection is facilitated by the process of lowering the hilar plate. 19 The hilar plate is a fusion of connective tissue that encompasses the biliary and vascular elements of the hilum. It is actually the invagination of Glisson's capsule at the hilum. With the liver retracted upward, an incision can be placed at the base of the quadrate lobe, or segment IV, just above the hilum. Gentle dissection directed centrally into the liver reveals a relatively avascular plane of fused connective tissue. This maneuver elevates a lip of liver and exposes the main bifurcation of the bile duct as well as a generous extrahepatic length of left hepatic duct. Excessive bleeding from liver parenchyma during this procedure usually indicates that the wrong plane has been entered, and dissection needs to be closer to the hilar structures. This parenchymatous bleeding from the hilum can usually be controlled with gauze packs, direct pressure, time, and occasionally, topical thrombostatic agents. Arterial bleeding encountered during hilar dissection can usually be traced to a point source, whereas bleeding from the portal vein tends to well up and be more difficult to visualize. The left hand placed behind the porta hepatis can help deliver the area of interest toward the incision and at the same time permits partial occlusion of inflow. For complicated rents that require more than a suture or two, it is best to apply the formal Pringle maneuver and repair the damage precisely. Formal Resection Division ofhilar structures for right or left hepatectomy should proceed in the order of artery, bile duct, and portal vein. The arteries are fairly simple to dissect, clamp, and suture ligate. At times, circumferential control of one of the main bile duct branches, particularly the right, can be difficult. The ducts lie immediately over their respective portal vein branches. Blunt


1373

dissection behind the duct might result in lacerating the vein. In this circumstance, it is better to place stay sutures in the duct on either side of the desired line of transection. With gentle traction directed anteriorly on the stay sutures, the duct can be incised with a knife through the lumen and back wall toward the underlying vein. The traction sutures can be used to elevate the duct, facilitating the creation of a plane between duct and vein. The ductal lumen is oversewn with care to avoid narrowing the bifurcation. Should the hilar dissection prove difficult, it is still possible to perform formal lobar hepatectomy using an initial Pringle maneuver and achieving control of the major hilar structures within the liver parenchyma. Parenchymal division is usually started only after exposure of the junction of the hepatic veins with the inferior vena cava and control of the hilum. When the hepatic artery and portal vein have been ligated, a line of demarcation will be obvious on the liver surface. For segmental resection, the line of transection is planned based on the course of the hepatic vein and its branches. Glisson's capsule is first scored using the electrocautery. The parenchyma is divided using any of several available means. The principal goals are to move the relatively amorphous liver tissue out of the way to expose the hidden arteries, ducts, and biliary radicles so they can be ligated before transection. The finger fracture technique relies on tactile differences between the various structures to accomplish this exposure. The tip of the suction probe can be a good dissecting instrument. An alternative is to crush the liver tissue with Kelly clamps and release the clamps to expose ducts and vessels. The electrocautery serves to control the smallest bridging ducts and vessels, whereas all larger structures should be tied in continuity. Vibrating ultrasonic devices have become popular. They permit fairly precise dissection and possibly less blood loss but are more time consuming and do not work as well in a fibrous liver. The most critical point of parenchymal transection is the time at which the hepatic veins are encountered. These veins are large and friable and receive multiple large side branches. The temptation to pass a right-angle clamp around their posterior aspect must be resisted until they have clearly been dissected circumferentially. When adequately exposed, the vein is clamped with a right-angle clamp and the remaining resection completed. An angled vascular clamp is placed just beyond the right-angle clamp, and the first clamp is removed. The venous stump is oversewn with a nonabsorbable vascular suture. Special attention is given to the raw edge of the liver to ensure hemostasis and search for possible leakages of bile. Thermocautery and fine sutures usually suffice to control points of hemorrhage. Topical thrombostatic agents may be applied when a general ooze is present. Coagulation factors should be checked and appropriately replaced when a specific deficiency is encountered. Large mattress sutures across the exposed surface are avoided. Finally, adequate closed suction drains are placed to eliminate fluid collections and dead space.

SPECIAL PROBLEMS DURING HEPATIC RESECTION One of the more complicated problems that will be encountered is either inadvertent or intentional interruption of the critical blood supply to

1374

WILLIAM

J.

SCHIRMER ET AL.

the hepatic remnant. For centrally located tumors, achieving an adequate margin may entail sacrifice of a segment of hepatic artery or portal vein. When the problem is recognized early, a decision regarding the appropriateness of resection can be made. When the extent of the tumor is not discovered until late in the resection, the decision must be made whether tumor will be left behind or whether it should be resected with the vessel. For some tumors, vascular involvement clearly precludes resectability; however, other slower growing tumors, particularly in young patients (e.g., fibrolamellar carcinoma), have been resected with the portal venous bifurcation with excellent long-term results. 3 . 28. 61 Occasionally, distortions of anatomy or inadvertent vascular injury require restoration of vascular continuity. Portal venous continuity can be restored in several ways. The combination of a generous Kocher maneuver and full liver mobilization makes primary end-to-end repair possible for defects of as much as 2 to 3 cm. For larger defects, the gap is bridged with a graft of a short segment of internal jugular vein. When sacrifice of the portal venous bifurcation is part of the planned procedure, some advance thought should be given to harvesting a vein before dividing the portal vein to minimize clamp time. The hepatic arteries are usually fragile and easily injured. As mentioned earlier, during left hepatectomy, we encountered an intimal dissection after application of a clamp to the porta hepatis. While the abdomen was being closed, the liver became ischemic. Arterial perfusion to the residual right lobe was restored with a gastroduodenal artery-to-right hepatic arterial bypass. The same principles apply to arterial reconstruction that were mentioned for portal venous reconstruction. End-to-end anastomosis is possible for small defects. Neighboring arteries, including the left gastric and gastroduodenal, can often be mobilized and rotated toward the liver hilum to make up for modest defects. The saphenous vein is an ideal conduit when larger spans must be bridged.

INTRAOPERATIVE COMPLICATIONS OF CHOLECYSTECTOMY

Deaths after cholecystectomy in patients less than 50 years of age are extremely rare, and rates of common bile duct injury are about 1 in 1000. 13. 15, 31, 45 Dissolution methods or techniques of extracorporeal shock wave lithotripsy have not displaced standard cholecystectomy as the gold standard of calculus treatment. The latest treatment modality to be introduced is laparoscopic cholecystectomy. Like standard cholecystectomy, it achieves the goal of definitively removing the diseased gallbladder. Its purported advantages include a shorter hospital stay, greater patient comfort, and cosmesis. 44 , 66 The few publications that are available coupled with presentations at national meetings and anecdotal reports suggest rates of common bile duct injury between o and 5%, a full order of magnitude higher than with standard cholecystectomy. Exsanguinating hemorrhage from trocar injury to the pelvic vessels and bowel perforations are also being reported. Proponents speak often of the learning curve, suggesting that these mishaps will disappear in time.


1375

Only time and careful study will determine whether the procedure has intrinsic characteristics that predispose to injury. Eleven patients with ductal injuries after laparoscopic cholecystectomy were referred to us over a 6-month period. In the same period, we saw only one patient with such an injury after standard cholecystectomy. Forms of presentation include ascites, jaundice, sepsis, external biliary fistula, and failure to thrive. We have been impressed with the extensive nature of the injuries, frequently requiring anastomosing multiple proximal ducts to a Roux-en-Y jejunal loop. The basic mechanism of injury is failure to identify the common duct. Risk factors include scarring, acute cholecystitis, obesity, and bleeding, The possibility of anatomic distortion of the bile duct by traction forces used during laparoscopic cholecystectomy needs to be considered (Figs. 1 through 3). Standard cholecystectomy became the safe operation it is today because of adequate exposure, knowledge of anatomic variants, and careful dissection. A safe laparoscopic cholecystectomy depends on exactly the same principles. With laparoscopic cholecystectomy, enlarging the incision may require conversion of the procedure to open cholecystectomy. We do not hesitate to do this when we do not feel entirely comfortable with the exposure, the anatomy, or the planes of dissection achieved during the laparoscopic procedure. To avoid trocar injury to bowel and major vessels,

Figure 1. Traction forces during open cholecystectomy. Caudal hand traction of duodenum helps to expose the common duct and minimizes angulation. (Reprinted by permission of the Lahey Clinic, Burlington, MA.)

1376

WILLIAM

J.

SCHIRMER ET AL.

Gallbladder

Figure 2. Traction forces during laparoscopic cholecystectomy can angulate the common duct. leading to a mistaken impression that it is the cystic duct. (Reprinted by permission of the Lahey Clinic, Burlington, MA.)

the Hassan trocar is placed under direct vision through a small umbilical incision. Principles of Standard Cholecystectomy The most critical dissection will be conducted near the insertion of the cystic duct into the common duct. This area is high and located much closer

Figure 3. A, Normal view. B, Inflammation and scarring can increase the difficulty of identifying the structures of Calot's triangle. (Reprinted by permission of the Lahey Clinic, Burlington, MA.)

f COMMON OPERATIVE PROBLEMS IN HEPATOBILIARY SURGERY

1377

to the midline than to the right flank. Vertically oriented incisions, such as a right paramedian or upper midline, do nicely in thinner patients with an acute costochondral angle. In the obese patient with a wider angle, exploration is best obtained through a transverse or right subcostal incision. Several techniques have been described for cholecystectomy. They differ primarily in the order in which the essential steps are carried out. We prefer preliminary dissection of Calot's triangle. At no point will that field be less distorted and free of blood staining than at the beginning of the procedure. In the presence of acute cholecystitis, early identification of the common duct is advisable. The cystic artery is clamped and ligated early. Similarly, a silk loop is placed but not tied around the cystic duct to prevent calculi from finding their way into the common duct during further dissection. The gallbladder can be dissected free from the liver bed with a minimum of blood loss. Keeping the field relatively dry makes anatomic variants easier to detect. After the gallbladder is dissected from its bed, it will remain attached only by the cystic duct. Sufficient length is left for operative cholangiography. Heroic efforts need not be expended in tracing the cystic duct to its junction with the common duct. This aggressive dissection may produce ductal injury. After cholangiography has been performed, the gallbladder is removed without unnecessary traction on the gallbladder and cystic duct. This traction may pull the common duct outward buckled on itself, leading to possible confusion with the distal aspect of the cystic duct. The cystic duct can be divided at any convenient point beyond the neck of the gallbladder and any impacted calculi. The length that is retained is probably not of major importance as long as it does not contain calculi. When difficulty is encountered during initial exposure of Calot's triangle, that area is abandoned, and the dissection proceeds from the fundus toward the neck of the gallbladder. This procedure results in a somewhat bloodier field and has the theoretical disadvantage of milking calculi from the gallbladder into the common duct. Many surgeons use this approach as a matter of routine, however, and discount this risk as nothing more than theoretical. It is critical that dissection be carried out immediately adjacent to the gallbladder to avoid injury to the common duct, right hepatic duct, and right hepatic artery. Cholecystostomy Occasionally, an elderly debilitated patient with acute cholecystitis is deemed too ill for standard cholecystectomy. More than anything else, these patients require decompression of the gallbladder. Tube cholecystostomy is an excellent means of controlling sepsis and can be performed rapidly using a short period of general anesthesia and an open technique. Attempting to perform this procedure under local anesthesia may lengthen the time and make it more painful to an already stressed patient. Trocar aspiration of the gallbladder contents followed by insertion of a de Pezzer or Foley catheter secured with a purse string suture plus drainage of the subhepatic space is the entire procedure. Cholecystectomy can be deferred to a later date or abandoned in the extremely high-risk patient. At the time of laparotomy for possible open cholecystostomy, when the

r 1378

WILLIAM

J.

I SCHIRMER ET AL.

findings suggest that removal of the gallbladder would be simple, this option should be considered because it avoids the morbidity and death associated with a second procedure. When the gallbladder is obviously necrotic or has perforated, tube cholecystostomy may be dangerous. A gangrenous gallbladder suggests an underlying vascular insult, and the gallbladder should be removed. Furthermore, when the gallbladder will not hold sutures, attempting to secure tubes may simply lead to rupture. When inflammation is severe and the common duct cannot be identified with certainty, however, it may be safest to perform partial cholecystectomy, place a tube in Hartmann's pouch, and drain the right subhepatic space. We have some limited and favorable experience, especially in patients with recent myocardial infarction, with percutaneous tube cholecystostomy. Studies are necessary to determine whether this method should be used routinely as an alternative to open cholecystostomy. Pericholecystic Abscess and Phlegmon Severe inflammation near Calot's triangle may make accurate determination of anatomy impossible. Rather than dissect blindly and risk serious hepatic arterial or major ductal injury, several options are available. Exploring the common bile duct at a point distal to the inflammatory process may permit the point of entry of the cystic duct to be identified. If that is not possible or is unsuccessful, tube cholecystostomy with the plan to reoperate in several weeks is a reasonable alternative. The third option is to perform partial cholecystectomy. This procedure entails opening the fundus of the gallbladder and thoroughly evacuating its contents. Rather than removing the gallbladder from the liver bed, it is left in place, and only the free peritonealized portion is excised. When the neck is accessible, a suture can be placed around it to prevent a biliary fistula. When the neck is not accessible, the infundibulum can simply be oversewn from within the gallbladder, preferably over a tube drain. This will permit a controlled fistula for subsequent cholangiographic studies and can provide a tract for instrumentation. The mucosa of the gallbladder wall still attached to the liver may be electrocoagulated. The right upper quadrant should be drained generously. Partial cholecystectomy is a useful technique in cirrhotic patients because it avoids the bloody plane between the gallbladder and the liver. Internal Biliary Fistulas Fistulous communications between the gallbladder and adjacent structures are not uncommon. 16, 27, 46, 53, 67 These fistulas are thought to develop by pressure necrosis of the gallbladder wall from large calculi. Inflammation causes the gallbladder to adhere to an adjacent structure, and the process of erosion continues. Occasionally, these fistulas are surprise findings because the patient may present with signs and symptoms referable to other organ systems. The classic example of this is gallstone ileus in which bowel obstruction is the presenting problem: 16, 24, 51 Another example is jaundice seen in the Mirizzi syndrome when a gallbladder or cystic duct calculus erodes into the common duct. 27, 32, 34 These fistulas are invariably associated with an aggressive inflammatory response and dense fibrosis that


1379

make dissection difficult. Indeed, the existence of a fistula is often not fully recognized until the mucosa of the neighboring structure is visualized. The treatment required depends on the site of communication and the patient's symptoms. In gallstone ileus, the goal of operation is to relieve bowel obstruction. When no symptoms are referable to the biliary tract, the biliary tree should probably not be approached at the first procedure. When a fistula from the gallbladder to duodenum or small bowel is dismantled, the defect in the bowel can usually be repaired primarily. Fistulas to the colon require dismantling. Untreated, they can be expected to produce a disabling choleric enteropathy and the ever-present risk of sepsis. Preoperative diagnosis permits formal bowel preparation. A fistula from the gallbladder to the hepatic duct is often not fully appreciated until the time of dissection. We have seen several jaundiced patients who were thought to have proximal bile duct tumors but after resection of the bile duct proved to have a cholecystohepatocholedochal fistula. When the communication is not recognized until the common duct is opened, the extent of damage to the duct must be assessed. Small defects may be closed over a T tube, but the degree of surrounding inflammation often makes this impossible. Severe defects that cannot be repaired primarily require proximal bilioenteric bypass. When a cholecystocholedochal fistula is suspected, the common duct may be opened more distally and attempts made to extract the offending calculus. It is not necessary to dissect the gallbladder all the way down to the common duct. A small remnant of gallbladder can be left attached to the duct and either oversewn or anastomosed to duodenum. When jaundice is present, proximal bilioenteric bypass probably should be performed initially rather than to make the assumption that a stricture will not persist after the inflammation subsides. Intraoperative Bleeding Troublesome bleeding during cholecystectomy comes either from the gallbladder fossa or from damage to major vascular structures within the porta hepatis. Excessive bleeding from the gallbladder bed in a patient who does not have cirrhosis should raise suspicion of an unrecognized coagulation defect or platelet abnormality. When the plane of dissection between gallbladder and liver is lost, the liver substance itself may be the source of bleeding. This bleeding will usually stop with time and pressure. When the blood is flowing at a fairly brisk rate, one should suspect injury to the terminal ramifications of the middle hepatic vein or to segmental branches of the right portal vein, either of which may course close to the surface in the gallbladder bed. These injuries will require sutures placed carefully in the gallbladder bed, taking great care not to compromise ducts or vessels near the hilum. Bleeding from the liver bed can be expected in patients with cirrhosis or other liver diseases. Consideration should be given to partial cholecystectomy. Significant bleeding from the region of the porta hepatis usually comes from the right hepatic artery after avulsion of the cystic artery. Clamps should not be used nor should large sutures be placed in an effort to control the bleeding. Fine sutures that will not occlude the right hepatic arterial lumen should be placed when the injury is fully visualized. The Pringle

1380

WILLIAM ]. SCHIRMER ET AL.

maneuver plus ample suction occasionally is needed to gain the desired exposure. Only as a last resort, when attempts to repair the damage have failed, should the right hepatic artery be ligated. Bile Duct Injury and Bile Duct Stricture Most benign biliary strictures are iatrogenic and are therefore preventable. The most common procedure during which the bile duct is injured is cholecystectomy followed by other biliary, gastric, and pancreatic procedures. The main tenet regarding repair of a damaged duct is that the operation be performed properly the first time. The operative success rates decrease measurably with each subsequent repair. 1. 5. 6. 8, 36, 49. 55 Repair of acute injuries achieves an 85% long-term rate of success. Patients with chronic or recurrent strictures often require multiple reoperations and accrue an estimated 5-year mortality rate approaching 30%. Ductal Injuries Recognized in the Operating Room Bile duct injury during cholecystectomy may be simple laceration of the duct but usually involves some degree of actual ductal tissue loss. The tissue loss may be partial, in which case one side of the wall has been removed but mucosal integrity of the duct is preserved on the opposite wall, or the duct may have been transected and excised over a considerable length. This latter injury is the type seen most frequently after laparoscopic cholecystectomy. Simple partial lacerations may be repaired primarily with interrupted sutures. Stents are not required as long as adequate luminal patency can be ensured. For minor tissue loss with a lateral defect, repair is best performed over a T tube. The vertical limb of the T tube exits the duct away from the repair and is left in place for several weeks after operation. When the duct has been transected completely without loss of length, a tension-free end-to-end anastomosis with interrupted sutures can be achieved. The same type of repair can be used in situations in which tissue loss is minimal, and the gap can be closed without tension after the Kocher maneuver. In about half the patients, however, end-to-end anastomosis results in stricture. Ductal injuries below the insertion of the cystic duct may be more amenable to reimplantation into the duodenum than to primary repair. In most instances of ductal injury, however, we prefer to perform Roux-en-Y hepaticojejunostomy at the first attempt. This would apply even when the hepatic ducts are of small diameter. At times, a large lateral rent cannot be repaired over a T tube. When an experienced biliary surgeon is not available, it is wise to preserve as much ductal length as possible rather than to risk failure of an anastomosis at the bifurcation. A reasonable approach is to insert a tube into the proximal duct, drain the subhepatic space, and refer the patient. Reoperation can be deferred to a later date when the chance of a successful bypass will greatly be enhanced by a virgin bifurcation. Ductal Injuries Recognized in the Early Postoperative Period Injuries that present in the early postoperative period take several forms. Complete ductal transection and ligation lead to jaundice within

¥


1381

days. In some patients, the proximal duct will be transected but not ligated. Bile will flow freely into the peritoneal cavity and cause bile peritonitis or it may exit the wound site, producing an external biliary fistula. An external biliary fistula is often associated with subhepatic collections and sepsis. In both of these scenarios, jaundice may not yet be evident, but the patient will have acholic stools. When the duct is partially obstructed or when infection is present, the presentation may be one of cholangitis, peritonitis, or abdominal sepsis. None of these signs is pathognomonic of bile duct injury. Postoperative jaundice may indicate the presence of a missed common duct calculus. External biliary fistula may result from dislodgment of the cystic duct tie or from damage to an unrecognized segmental duct draining directly into the gallbladder. Urgent reoperation is not necessary unless progressive peritonitis is obvious. It is better to treat the infection with antibiotics and attempt to determine the nature of the problem. The proximal extent of the injury must be identified. When the problem is retained common duct calculi, endoscopic retrograde cholangiopancreatography may be both diagnostic and therapeutic. This study may demonstrate that the main duct remains intact with extravasation coming from the cystic duct stump or from a more proximal segmental duct. In these situations, the fistula can usually be controlled with percutaneous drains, and a period of expectant management usually leads to spontaneous closure of the fistula. When the duct is truly interrupted, endoscopic retrograde cholangiopancreatography is of little value. Fistulography may outline the ductal anatomy proximal to the injury. When it does, this is the only imaging study necessary. When fistulography is not successful, percutaneous transhepatic cholangiography may be considered to outline proximal ductal anatomy, a technically difficult procedure in patients with a nondilated biliary tree. Preoperative demonstration of the precise point of injury is not always necessary when early reoperation is planned. Unless operation is to be delayed for an extended period in jaundiced patients, percutaneous catheters should not be left in place after percutaneous transhepatic cholangiography. Some authorities 5 . 57 favor a delayed approach to the repair of ductal injuries. They argue that early repair is more difficult because the ducts are thin walled and nondilated. With time, the fistulas begin to close, leading to jaundice and ductal dilation. Those authorities reason that delaying repair to this point increases the probability of success at the first operation. Early repair is usually favored in physically fit patients. Although the ducts are small, they are less likely to be encased in scar and fibrosis characteristic of long-standing fistula. Delaying operation places the patient at an ever-present risk of cholangitis and may convert an elective procedure to an emergency one. A chronic external biliary fistula is associated with adverse nutritional and electrolyte sequelae, and patients can rarely be coerced into drinking their bile. Even low levels of biliary obstruction can lead to irreversible biliary cirrhosis over time. The operative repair for most of these strictures is hepaticojejunostomy proximal to the stricture and often at or above the level of the hepatic bifurcation. The main priority is to find healthy duct above the point of

1382

WILLIAM

J.

SCHIRMER ET AL.

damage. If necessary, in high injuries, the lumen of the duct is enlarged by opening along the left hepatic duct to facilitate the anastomosis. 19 A precise mucosa-to-mucosa approximation is mandatory. A single layer of monofilament sutures is placed under magnification. In patients with subhepatic abscess or infected bile collections, percutaneous drainage before repair may be advisable. Often, however, drainage of this collection and repair can be achieved in the same procedure. Late Ductal Injuries and Strictures Patients who present with symptomatic late biliary stricture will almost certainly require definitive surgical correction. Although percutaneous or endoscopic dilation of these strictures is often successful initially, subsequent restricturing is the rule. 37. 65 Earlier operation is preferable to the possibility of confronting cholangitis and hepatic abscess. For late strictures, proximal bilioenteric bypass is performed. At times, the repair is divided into two stages. In patients with established biliary cirrhosis and variceal hemorrhage and extensive varices within the porta hepatis, hilar dissection is treacherous, and massive blood loss may be encountered. Consideration is given to a primary portosystemic shunt, 55 preferably away from the subhepatic area (e.g., splenorenal shunt, mesocaval shunt).

DIFFICULTIES DURING BILIOENTERIC BYPASS Internal biliary decompression into a segment of bowel is the preferred form of long-term management of both benign and malignant biliary strictures. For malignant disease, the site of anastomosis is variable and depends on the location and nature of the tumor, the availability of suitable enteric conduit, and whether the procedure is strictly palliative or is performed in association with a major bile duct or hepatic resection. Regardless of location or indication, several principles of bilioenteric bypass apply universally. The first is that a healthy segment of duct or ducts located proximal to the point of obstruction and that drains the entire biliary tree must be located. A suitable segment of well-perfused bowel that reaches the site of anastomosis without tension is necessary. A direct mucosa-to-mucosa anastomosis must be carried out to ensure long-term patency. Locating the Duct The hepatic bifurcation can usually be exposed using the technique referred to as lowering the hilar plate. 19 This technique permits access to the bifurcation and exposes a generous extrahepatic length of the left hepatic duct. During exploration for jaundice caused by proximal biliary obstruction, one of the lobes of the liver may be atrophied and the other hypertrophied. This is the result of long-standing obstruction of the biliary tree, and often the arterial supply as well, to one side of the liver. The affected side shrinks, and the unaffected side hypertrophies to compensate for the


1383

functional deficit. These patients often do not come to medical attention until the disease process begins to encroach on the side that had earlier been spared. This results in rotation of the hilum toward the atrophic side. These possible distortions of anatomy must be kept in mind to prevent inadvertent damage to or misidentification of ducts and vessels. A principal goal of bilioenteric bypass is to decompress all of the obstructed ducts. Preoperative or intraoperative cholangiography may be of value in determining which ducts will be in communication with the enteric conduit. At times, not all ducts need drainage, however. Unfortunately, hilar lesions often separate the right and left systems from one another; therefore, a single biliary bypass procedure will often not accomplish the goal of complete decompression. When a hilar tumor is locally resectable from a technical standpoint, even in the presence of local or distant metastatic disease, it may be preferable to remove the mass and perform multiple hilar anastomoses from between two and six ducts to a single loop of bowel. The alternative is to leave the tumor in place and attempt independent anastomoses to the right and left ductal systems, a proposition often more difficult on the right. Another alternative is to combine extensive hepatic resection with hilar resection. This technique is especially attractive when the tumor extends more to one side of the liver and spares the other side. Hepaticojejunostomy to the main duct or segmental ducts of the residual liver restores biliary intestinal continuity. Hepatectomy is also a consideration when one side of the liver is obstructed and infected and the other half is spared. The obstructed half of the liver usually has extensive tumor into segmental duts beyond the hepatic bifurcation with ascending cholangitis and multiple abscesses. It is often impossible to drain all segmental branches. With a large unresectable hilar tumor, it may be difficult to expose the left hepatic duct at the base of segment IV.I. 4 The alternative is to expose the duct more peripherally by moving to segment III. 25 This is accomplished by dividing the bridge of liver tissue often present between segments III and V. Dissection is carried out along the round ligament in the umbilical fissure. The termination of the round ligament will be the left branch of the portal vein. The fetal communications between the ligament and vein have usually become fibrous bands that fan out in a crow's foot fashion. Mter division of these attachments, the left branch of the portal vein can be retracted slightly inferiorly. The anterior segment III duct will be located above and slightly behind the left portal vein. Longmire and Sanford26 described a procedure that exposes the segment II duct. Their technique involves removing a portion of the left lateral lobe. The transected end of the duct is located on the raw surface of the liver and sutured to a jejunal loop. The drawbacks to this technique are the inevitable blood loss and the small caliber of duct usually found in this location. The tendency for these peripheral anastomoses to restricture limits their use, especially in benign disease. It is more difficult to locate an intrahepatic duct suitable for anastomosis within the right side of the liver. The main right hepatic duct has a short extrahepatic course beyond the bifurcation. Nagasue et al 40 advocated an approach to the segment V duct through the gallbladder fossa.

1384

WILLIAM

J.

SCHIRMER ET AL.

Surgeon and radiologists need to confer in advance regarding the strategy for managing these difficult hilar lesions. When it is possible that effective internal drainage cannot be achieved to a given segment, placing a percutaneous drain in that permanently obstructed segmental duct converts it to a permanent external biliary fistula. Furthermore, what may have been sterile bile will now be contaminated. As the obstructive process continues in that half of the liver, cholangitis and abscess formation will undoubtedly develop. In the absence of intervening sepsis, the liver on the side of an obstructed duct may simply atrophy quietly. A strategy that preserves biliary drainage from only one side of the liver is justified in these patients. Preparation of Intestinal Conduit Either a Roux-en-Y limb or a simple loop of jejunum is used for anastomosis. When a loop is used, side-to-side jejunojejunostomy is fashioned to divert most of the enteric contents away from the anastomosis. The theoretical advantage of the Roux-en-Y limb is more thorough diversion of these secretions. With a Roux-en-Y limb, a couple of extra centimeters of bowel length can be obtained compared with a simple loop. On the other hand, the blood supply to a loop of jejunum may be better than that to a Roux-en-Y limb in elderly patients who have fixed vascular obstructive disease or in patients with tumoral involvement of the mesentery. The duodenum can often be mobilized sufficiently for hilar anastomosis, but we avoid its use for the simple reason that it is much more difficult to repair duodenum than jejunum when subsequent revision of the anastomosis is required. The Anastomosis A stay suture is placed in the anterior duct wall. The anastomosis begins with a corner suture (most often 4-0 or 5-0 polydioxanone) in the far wall in such a way that the knot will be on the outside. The entire back row of sutures is placed so that the knots will lie within the anastomosis. All sutures are tagged, and none is tied at this point. When the near corner suture has been placed, all clamps tagging the sutures are held up under gentle tension, and the bowel is positioned against the bile duct. The assistant maintains the position of the bowel while the surgeon ties each knot, taking care always to direct tension toward the bile duct rather than away from it. The sutures in the back wall are cut. When a stent is being used, it should have been inserted into the duct before the anastomosis was started and should be inserted into the bowel lumen at this time. The anterior row is completed with interrupted sutures. All knots will be tied on the outside of the lumen after all sutures have been placed. The need to stent the anastomosis is controversial. Stents may be optional in patients with benign disease (other than sclerosing cholangitis) in whom a precise mucosa-to-mucosa anastomosis can be achieved. When the probability of restricture is high because of advancing disease, stents are used. For hilar anastomosis, transhepatic tubes traverse the anastomosis. When transhepatic stents are used, it is important to ensure that the side holes do not protrude beyond the liver surface. To avoid slippage, the


1385

tubes are tied to the anastomosis using one of the back wall sutures as a point of anchoring before completing the anastomosis. All bilioenteric anastomoses should be drained. The preferred position is dependent but not adjacent to the suture line. When transhepatic tubes are used, drains should be placed over the liver surface in the vicinity of their exit site.

POSTOPERATIVE BILIARY FISTULA Postoperative biliary fistula may be a complication of cholecystectomy, common bile duct exploration, repair of bile duct injury, bilioenteric bypass, liver resection, drainage of liver cysts and abscess, and a host of other procedures. Management must be tailored to the underlying condition. Bile leaking through the surgical incision or from a drain after cholecystectomy immediately raises the suspicion of a major ductal injury. It may also represent damage to smaller subvesical ducts or failure to secure the cystic duct adequately. Biliary drainage after removal of a T tube is not uncommon for a few days but if persistent should arouse suspicion of a retained calculus or a missed distal malignant lesion. Carefully performed bilioenteric anastomoses rarely leak for more than a few days, and when they do, a technical error, such as suture line disruption or failure to incorporate a significant duct within the anastomosis, must be suspected. Alternatively, local factors, such as abscess or ischemic necrosis of the duct or bowel wall, must be considered. A persistent biliary fistula after hepatectomy may result from failure to ligate the bile ducts adequately on the transected surface or may be related to a bilioenteric anastomosis. Prolonged biliary fistulas may lead to fluid and electrolyte depletion and insidious nutritional disturbances. Because of variable degrees of resistance to the egress of bile, cholangitis or even frank jaundice may be seen. In the absence of peritonitis, abscess, recurrent cholangitis, jaundice, or other reasons for early exploration, the best approach to a biliary fistula is a period of expectant medical management that can usually be carried out on an outpatient basis and does not require long-term bowel rest and total parenteral nutrition. Unless a distal obstruction or complete division of the bile duct is a possibility, most of these fistulas will resolve spontaneously. The initial work-up should be directed toward resolving whether the main duct remains in continuity with the bowel and whether a fixed distal obstruction is present. Tube cholangiography or fistulography is the simplest test. When bile duct continuity is demonstrated with a single point of extravasation and the duct empties into the bowel, the fistula can be expected to close over time. Percutaneous transhepatic cholangiography may be necessary in the patient with jaundice when fistulography does not provide the necessary information. Endoscopic retrograde cholangiopancreatography may also be helpful but will not always demonstrate the proximal extent of obstruction. A 4- to 6-week trial of conservative management is instituted for

1386

WILLIAM

J.

SCHIRMER ET AL.

uncomplicated fistulas. Early operative intervention is chosen for complete ductal transection or for situations complicated by cholangitis or jaundice. At the 6-week interval, the underlying cause and extent of damage must be re-evaluated before operative intervention. Ductal injuries after cholecystectomy will require proximal bilioenteric bypass as outlined previously. Retained common duct calculi or distal tumors should be treated by appropriate methods on an individual basis. Biliary fistulas that persist after hepatic resection can be observed further or treated in one of three ways: the involved segment of liver that is responsible can be removed, the leaking duct simply oversewn, or an anastomosis between the point of leakage and a Roux-en-Y limb of jejunum carried out. The technical demands of these reoperative procedures can be considerable, and they should not be undertaken by the occasional hepatobiliary surgeon.

SUMMARY The pace of change in hepatobiliary surgery requires a sound foundation in basic surgical principles. Further reductions in morbidity and mortality rates and appropriate use of alternative therapies require careful attention to preoperative risk assessment and patient selection. To operate safely and successfully on the liver and bile ducts, the surgeon must be well versed in normal and variant hepatobiliary anatomy, understand the underlying disease and therapeutic alternatives, and know techniques of reoperative biliary surgery. Surgeons who operate on the gallbladder must be prepared to confront a host of unexpected and difficult operative problems. Bile duct injuries must be repaired properly at the first attempt. Complex biliary operations require a great level of technical expertise and judgment to obtain successful results and should only be undertaken by experienced hepatobiliary surgeons. As proficiency with the more routine procedures improves, increasingly complex and extensive procedures become possible. We must constantly police ourselves to be certain that these more extensive procedures truly benefit our patients.

REFERENCES 1. Bismuth H: Postoperative strictures of the bile duct. In Blumgart LH (ed): The Biliary Tract. Clinical Surgery International, vol 5. Edinburgh, Churchill Livingstone, 1982, pp 209-218 2. Bismuth H: Surgical anatomy and anatomical surgery of the liver. World J Surg 6:3-9, 1982 3. Blumgart LH, Hadjis NS, Benjamin IS, et al: Surgical approaches to cholangiocarcinoma at confluence of hepatic ducts. Lancet 1:66-70, 1984 4. Blumgart LH, Kelley CJ: Hepaticojejunostomy in benign and malignant high bile duct stricture: Approaches to the left hepatic ducts. Br J Surg 71:257-261, 1984 5. Blumgart LH, Kelley CJ, Benjamin IS: Benign bile duct stricture following cholecystectomy: Critical factors in management. Br J Surg 71:836-843, 1984 6. Braasch JW: Current considerations in the repair of bile duct strictures. Surg Clin North Am 53:423-433, 1973


1387

7. Buzby GP, Mullen JL, Matthews DC, et al: Prognostic nutritional index in gastrointestinal surgery. Am J Surg 139:160-167, 1980 8. Cattell RB, Braasch JW: Repair of benign strictures of the bile duct involving both or single hepatic ducts. Surg Gynecol Obstet 110:55-60, 1960 9. Couinaud C: Le foie les hepatectomies elargies. In: Etudes Anatomiques et Chirurgicales. Paris, Masson, 1957, pp 400-409 10. Denning DA, Ellison EC, Carey LC: Preoperative percutaneous transhepatic biliary decompression lowers operative morbidity in patients with obstructive jaundice. Am J Surg 141:61-65, 1981 11. Dixon JM, Armstrong CP, Duffy SW, et al: Factors affecting morbidity and mortality after surgery for obstructive jaundice: A review of 373 patients. Gut 24:845-852, 1983 12. Fortner JG, Kim DK, Maclean BJ, et al: Major hepatic resection for neoplasia: Personal experience in 108 patients. Ann Surg 188:363-371, 1978 13. Ganey JB, Johnson PA Jr, Prillaman PE, et al: Cholecystectomy: Clinical experience with a large series. Am J Surg 151:352-357, 1986 14. Ger R: Surgical anatomy and the liver. Surg Clin North Am 69:179-192, 1989 15. Gilliland TM, Traverso LW: Modern standards for comparison of cholecystectomy with alternative treatments for symptomatic cholelithiasis with emphasis on long-term relief of symptoms. Surg Gynecol Obstet 170:39-44, 1990 16. Glenn F, Reed C, Grafe WR: Biliary enteric fistula. Surg Gynecol Obstet 153:527-531, 1981 17. Goldsmith NA, Woodburne RT: The surgical anatomy pertaining to liver resection. Surg Gynecol Obstet 105:310-318, 1957 18. Hatfield AR, Tobias R, Terblanche J, et al: Preoperative external biliary drainage in obstructive jaundice: A prospective controlled clinical trial. Lancet 2:896-899, 1982 19. Hepp J, Couinaud C: L'abord et l'utilisation du canal hepatique gauche dans les reparations de la voie biliare principale. Presse Med 64:947-948, 1956 20. Iwatsuki S, Shaw BW Jr, Starzl TE: Experience with 150 liver resections. Ann Surg 197:247-253, 1983 21. Iwatsuki S, Starzl TE: Personal experience with 411 hepatic resections. Ann Surg 208:421434, 1988 22. Iwatsuki S, Todo S, Starzl TE: Excisional therapy for benign hepatic lesions. Surg Gynecol Obstet 171:240-246, 1990 23. Knaus WA, Draper EA, Wagner DP, et al: APACHE II: A severity of disease classification system. Crit Care Med 13:818-829, 1985 24. LeBlanc KA, Barr LH, Rush BM: Spontaneous biliary enteric fistulas. South Med J 76:1249-1252, 1983 25. Longmire WP Jr, Lippman HN: Intrahepatic cholangiojejunostomy: An operation for biliary obstruction. Surg Clin North Am 36:849-863, 1956 26. Longmire WP Jr, Sanford MC: Intrahepatic cholangiojejunostomy with partial hepatectomy for biliary obstruction. Surgery 24:264-276, 1948 27. Lygidakis NJ: Spontaneous internal biliary fistulae: Early surgery for prevention, radical surgery for cure: A report of 75 cases. Med Chir Dig 10:695-699, 1981 28. Lygidakis NJ, van der Heyde MN, van Dongen RJ, et al: Surgical approaches for unresectable primary carcinoma of the hepatic hilus. Surg Gynecol Obstet 166:107114, 1988 29. Manfredi D, Campioni N, Sorvillo G, et al: Our experience with resection of primary and secondary liver tumours. J Surg Oncol 28:284-289, 1985 30. McPherson GA, Benjamin IS, Hodgson HJ, et al: Pre-operative percutaneous transhepatic biliary drainage: The results of a controlled trial. Br J Surg 71:371-375, 1984 31. McSherry CK: Cholecystectomy: The gold standard. Am J Surg 158:174-178, 1989 32. McSherry CK, Ferstenberg H, Virshup M: The Mirizzi syndrome: Suggested classification and surgical therapy. Surg Gastroenterol1:219-225, 1982 33. Mimura H, Takakura N, Ohno Y, et al: Determination of the extent of feasible hepatic resection from hepatic blood flow. World J Surg 10:302-310, 1986 34. Mirizzi PL: Sindrome del conducto hepatico. J Int Chir 8:731-777, 1948 35. Mizumoto R, Kawarada Y, Suzuki H: Surgical treatment of hilar carcinoma of the bile duct. Surg Gynecol Obstet 162:153-158, 1986 36. Moossa AR, Mayer AD, Stabile B: Iatrogenic injury to the bile duct: Who, how, where? Arch Surg 125:1028-1031, 1990

1388

WILLIAM

J.

SCHIRMER ET AL.

37. Mueller PR, vanSonnenberg E, Ferrucci JT Jr, et al: Biliary stricture dilatation: Multicenter review of clinical management in 73 patients. Radiology 160:17-22, 1986 38. Muller JM, Brennan U, Dienst C, et al: Preoperative parenteral feeding in patients with gastrointestinal carcinoma. Lancet 1 :68-71, 1982 39. Nagao T, Inoue S, Mizuta T, et al: One hundred hepatic resections: Indications and operative results. Ann Surg 202:42-49, 1985 40. Nagasue N, Hirose S, Yukaya H: Right hepatic duct-duodenostomy in the treatment of nonresectable carcinoma of the hepatic hilus. Chir Epato Biliare 2:36-67, 1983 41. Nakayama T, Ikeda A, Okuda K: Percutaneous transhepatic drainage of the biliary tract: Technique and results in 104 cases. Gastroenterology 74:554-559, 1978 42. Nimura Y, Hayakawa N, Kamiya J, et al: Hepatic segmentectomy with caudate lobe resection for bile duct carcinoma of the hepatic hilus. World J Surg 14:535-544, 1990 43. Northover JM, Terblanche J: A new look at the arterial supply of the bile duct in man and its surgical implications. Br J Surg 66:379-384, 1979 44. Peters JH, Ellison EC, Innes JT, et al: Safety and efficacy oflaparoscopic cholecystectomy: A prospective analysis of 100 initial patients. Ann Surg 213:3-12, 1991 45. Pickleman J, Gonzalez RP: The improving results of cholecystectomy. Arch Surg 121:930934, 1986 46. Piedad OH, Wels PB: Spontaneous internal biliary fistula, obstructive and nonobstructive types: Twenty-year review of 55 cases. Ann Surg 175:75-80, 1972 47. Pitt HA, Cameron JL, Postier RG, et al: Factors affecting mortality in biliary tract surgery. Am J Surg 141:66-72, 1981 48. Pitt HA, Gomes AS, Lois JF, et al: Does preoperative percutaneous biliary drainage reduce operative risk or increase hospital cost? Ann Surg 201:545-553, 1985 49. Pitt HA, Miyamoto T, Parapatix SK, et al: Factors influencing outcome in patients with postoperative biliary strictures. Am J Surg 144:14-21, 1982 50. Poenaru D, Christou NV: Clinical outcome of seriously ill surgical patients with intraabdominal infection depends on both physiologic (APACHE II score) and immunologic (DTH score) alterations. Ann Surg 213:130-136, 1991 51. Rau WS, Matern S, Gerok W, et al: Spontaneous cholecystocolonic fistula: A model situation for bile acid diarrhea and fatty acid diarrhea as a consequence of a disturbed enterohepatic circulation of bile acids. Hepatogastroenterology 27:231-237, 1980 52. Ryan WH, Hummel BW, McClelland RN: Reduction in the morbidity and mortality of major hepatic resection: Experience with 52 patients. Am J Surg 144:740-743, 1982 53. Sane SM, Sieber WK, Girdany BR: Congenital bronchobiliary fistula. Surgery 69:599608, 1971 54. Schwartz SI: Biliary tract surgery and cirrhosis: A critical combination. Surgery 90:577583, 1981 55. Sedgwick CE, Poulantzas JK, Kune GA: Management of portal hypertension secondary to bile duct strictures: Review of 18 cases with splenorenal shunt. Ann Surg 163:949953, 1966 56. Sesto ME, Vogt DP, Hermann RE: Hepatic resection in 128 patients: A 24-year experience. Surgery 102:846-851, 1987 57. Smith EE, Bowley N, Allison DJ, et al: The management of post-traumatic intrahepatic cutaneous biliary fistulas. Br J Surg 69:317-318, 1982 58. Stephenson KR, Steinberg SM, Hughes KS, et al: Perioperative blood transfusions are associated with decreased time to recurrence and decreased survival after resection of colorectalliver metastases. Ann Surg 208:679-687, 1988 59. Stimpson RE, Pellegrini CA, Way LW: Factors affecting the morbidity of elective liver resection. Am J Surg 153:189-196, 1987 60. Stone HH: Major hepatic resections in children. J Pediatr Surg 10:127-134, 1975 61. Sukaguchi S, Nakamura S: Surgery of the portal vein in resection of cancer of the hepatic hilus. Surgery 99:344-349, 1986 62. Thompson HH, Tompkins RK, Longmire WP Jr: Major hepatic resection: A 25-year experience. Ann Surg 197:375-388, 1983 63. Tsuzuki T, Ogato Y, lida S, et al: Hepatic resection in 125 patients. Arch Surg 119:10251032, 1984 64. Vetto JT, Hughes KS, Rosenstein R, et al: Morbidity and mortality of hepatic resection for metastatic colorectal carcinoma. Dis Colon Rectum 33:408-413, 1990


1389

65. Vogel SB, Howard RJ, Caridi J, et al: Evaluation of percutaneous transhepatic balloon dilatation of benign biliary strictures in high-risk patients. Am J Surg 149:73-79, 1985 66. Zucker KA, Bailey RW, Gadacz TR, et al: Laparoscopic guided cholecystectomy. Am J Surg 161:36-44, 1991 67. Zwemer FL, Coffin-Kwart VE, Conway MJ: Biliary enteric fistulas: Management of 47 cases in native Americans. Am J Surg 138:301-304, 1979

Address reprint requests to Ricardo L. Rossi, MD Department of General Surgery Lahey Clinic Medical Center 41 Mall Road Burlington, MA 01805

Prior inpatient admission increases the risk of post-operative infection in hepatobiliary and pancreatic surgery.

Systematic review of peri-operative nutritional support for patients undergoing hepatobiliary surgery.

Anesthesia for hepatobiliary surgery.

Common skin problems in children.

Common anal problems.

The post-operative course of head and neck tumour surgery with special reference to respiratory problems.

Minimally invasive hepatobiliary surgery: pioneering investigations regarding surgical treatment of hepatobiliary disease. Introduction.

Morbid obesity: problems associated with operative management.

Factors Affecting Surgical Site Infection Rates in Hepatobiliary Surgery.

Common eye problems among children.

Exchange makes progress: Hepatobiliary Surgery and Manuscript Writing Symposium cosponsored by HepatoBiliary Surgery and Nutrition and AME Publishing Company.

Newborn Skin: Common Skin Problems.

Prophylactic antibiotics used in patients of hepatobiliary surgery.

Common visual problems in children with disability.

Common methodological problems in MMPI research.

Managing common breastfeeding problems in the community.

Avoiding common errors in key feature problems.

State of the art in robotic hepatobiliary surgery.

HepatoBiliary Surgery and Nutrition - Message from the Editor-in-Chief.

Problems in day care surgery.

Pre-operative considerations in aesthetic facial surgery.

POST-OPERATIVE INSULIN REQUIREMENTS IN BARIATRIC SURGERY.

Operative Surgery in the Azamgarh Sudder Dispensary.

Common sexual problems of children and adolescents.