Definition of Hepaticojejunostomy Procedure
Laparotomy is performed through the previous Makuuchi incision and cholangiography is performed following catheterization of cystic duct stump. In LLDs with an external PTBD catheter, radiologist place a guide-wire through the catheter. The PTBD catheter is withdrawn with care and the rigid guide-wire is pushed-forward slowly under fluoroscopic observation (Fig.3a). The bile duct is determined by the bulging at the closest point on the cut surface. A bile duct orifice that is wide enough to perform an anastomosis is obtained using cavitron ultrasonic surgical aspirator to dissect the periductal liver parenchyma. Following retraction of guide-wire, PTBD catheter was inserted and HJ anastomosis was performed. In cases that have external-internal PTBD catheter, it is easy to see the catheter after the damaged extrahepatic bile duct is explored. In these cases, HJ is performed over the PTBD catheter and distal end of the catheter was advanced into the Roux limb (Fig.3b). HJ anastomoses are performed with interrupted suture using 6/0 monofilament polydioxanone sutures, stiches remained outside. Following the anastomosis, patency of bile ducts is controlled with intraoperative cholangiography via PTBD catheter. PTBD catheters are with-drawn in LLDs without bile leaks on cholangiography performed on postoperative week 4-6.