What is the recommended size of a hepaticojejunostomy (hepaticojejunostomy is a surgical procedure that involves creating a connection between the hepatic duct and the jejunum)

Optimal Size for Hepaticojejunostomy Anastomosis

The recommended size for hepaticojejunostomy anastomosis should be an adequate caliber with a minimum width of 8-10 mm to prevent stricture formation, using healthy bile duct tissue with normal mucosa for optimal outcomes. 1, 2

Anatomical Considerations for Hepaticojejunostomy

Preparation of the Bile Duct

• Remove all ischemic and scarred tissue from the bile duct stump to ensure healthy tissue for anastomosis 1
• Expose the proximal bile duct fully using appropriate surgical approaches (anterior, superior, or posterior) 2
• Follow the principle of "bile duct is three rather than two" to avoid missing the right posterior hepatic duct 1
• For type II1 bile duct stenosis:
  • Incise the proximal wall of the extrahepatic bile duct
  • If necessary, extend the incision to the left hepatic duct 1
  • For connected left and right hepatic ducts: reveal anterior wall of left hepatic duct first, then extend rightwards 1
  • For disconnected ducts: remove sclera tissue and suture medial margins together to form a single stoma 1

Creating an Optimal Anastomosis

• The anastomotic stoma must be of adequate caliber (minimum 8-10 mm width) 3
• Technical difficulties arise when the biliary stump is thin (<8 mm) or short (<0.5 cm) 3
• For high-level bile duct injuries, create a wide anastomosis by extending the incision from left to right hepatic duct 1

Technical Aspects of Anastomosis

Suturing Technique

• Use fine coincidence technique with non-invasive suture needle for mucosal-mucosal anastomosis 1
• Select 5-0 or 6-0 fine suture material based on bile duct wall thickness 1
• Follow principles of:
  • Single-layer stitching
  • Uniform margins
  • Appropriate density
  • Moderate knotting strength
  • Tension-free anastomosis 1

Critical Elements for Success

• Ensure tension-free bilioenteric anastomosis with good mucosal apposition 1
• Maintain well-vascularized ducts to prevent ischemia 1, 2
• Create anastomosis tight enough to prevent bile leakage but not so tight as to damage blood supply 1
• Avoid excessive tightness that could compromise tissue vascularity 1

Outcomes and Complications

Risk Factors for Stricture Formation

• Anastomotic strictures occur in 4-20% of cases 2, 4
• Higher risk with:
  • Male gender (OR 6.7) 4
  • Associated vascular injury 2
  • High-level bile duct injury 2
  • Sepsis or peritonitis 2
  • Postoperative bile leakage 2

Pitfalls to Avoid

• Inadequate exposure leading to missed ducts, especially the right posterior hepatic duct 2
• Creating anastomosis under tension or with poor mucosal apposition 2
• Excessive dissection compromising bile duct blood supply 2
• Using end-to-end anastomosis, which has higher failure rates 1

Drainage Considerations

• Short-term drainage (≤3 months) may be considered in specific cases:
  • Unsatisfactory anastomosis
  • Significant inflammation of bile duct wall
  • Presence of intrahepatic bile duct stones 1, 2
• Conventional placement of bile duct drainage is not routinely necessary 1

By creating a hepaticojejunostomy with adequate size (minimum 8-10 mm), using healthy tissue, and following proper technical principles, surgeons can minimize the risk of stricture formation and optimize long-term outcomes for patients.