What are the key considerations for hepaticojejunostomy (creation of a surgical connection between the hepatic duct and jejunum) in terms of surgical anatomy?

Surgical Anatomy for Hepaticojejunostomy

The fundamental principle of hepaticojejunostomy is creating a tension-free, mucosa-to-mucosa biliary-enteric anastomosis using healthy, non-ischemic, non-inflamed, and non-scarred bile duct tissue. 1

Critical Anatomical Principles

Bile Duct Preparation

• Remove all scar tissue and devitalized tissue from the proximal bile duct stump before anastomosis, as anastomosis performed on ischemic or scarred tissue is the primary cause of postoperative anastomotic leakage and stricture formation 1
• Identify and expose healthy bile duct mucosa with adequate caliber, ensuring the proximal bile duct has normal mucosal characteristics before proceeding 1, 2
• For thermal injuries, the boundaries of ischemia and devitalization are often unclear at the early stage, making accurate determination of viable tissue planes difficult and increasing risk of anastomotic failure 1

Anatomical Level Considerations

• For low strictures (>2 cm from hepatic confluence), perform a low end-to-side hepaticojejunostomy at the common hepatic duct level 3
• For high strictures or recurrent injuries, use the Hepp-Couinaud approach, which involves anastomosis to the left hepatic duct after exposing it along the base of segment IV 3, 4
• When both left and right hepatic ducts are transected, remove scar tissue from both stumps and create a unified anastomotic stoma by suturing the medial margins of the left and right hepatic ducts together before performing the jejunal anastomosis 2

Technical Specifications

Anastomotic Technique

• Use fine suture technique with 5-0 or 6-0 sutures, selecting size according to bile duct wall thickness, with either absorbable or non-absorbable materials acceptable 2
• Follow principles of single-layer stitching, uniform margins, appropriate stitch density, moderate knotting strength, and tension-free anastomosis 2
• Ensure good mucosal apposition between bile duct and jejunal mucosa, as this is essential for long-term patency 1

Vascular Considerations

• Preserve blood supply to the bile duct during dissection, as vascularized ducts are the mainstay of successful reconstruction 1
• Associated vascular injury (particularly hepatic artery injury) is associated with worse outcomes, including higher rates of anastomotic strictures and biliary cirrhosis 1
• Do not attempt systematic immediate repair of isolated right hepatic artery injuries, as the benefit/risk ratio must be carefully evaluated 1

Roux-en-Y Limb Construction

• Create a Roux-en-Y jejunal limb of adequate length (typically 40-60 cm) to prevent reflux of enteric contents into the biliary tree 1, 4
• The jejunal limb should reach the hilum without tension, ensuring the anastomosis remains tension-free in all positions 1
• This technique avoids the hazards of sump syndrome and enteric reflux seen with choledochoduodenostomy 4

Timing and Surgical Expertise

Optimal Timing

• For injuries detected intraoperatively or within 72 hours, early repair by an experienced HPB surgeon can be performed 1
• For injuries diagnosed between 72 hours and 3 weeks, delay definitive repair until inflammation resolves (minimum 3 weeks), using percutaneous drainage and antibiotics in the interim 1
• Definitive repair is typically performed 4-6 weeks after effective control of inflammation when tissue planes are clearer 2

Surgeon Expertise

• Referral to a tertiary HPB center is essential if local HPB expertise is unavailable, as primary repair attempts by non-expert surgeons have higher failure rates, morbidity, and mortality 1
• The expertise of the HPB surgeon in the tertiary care setting is crucial, particularly in the presence of increased tissue fragility 1

Expected Outcomes

• Long-term patency rates of 80-90% are achievable when performed correctly by experienced surgeons 5, 3
• Anastomotic stricture rates range from 4.1% to 69%, with most studies reporting 10-20%, occurring at a median time of 11-30 months postoperatively 1
• Associated vascular injury, level of bile duct injury, sepsis/peritonitis, and postoperative bile leakage are associated with worse outcomes 1

Common Pitfalls to Avoid

• Never perform anastomosis on ischemic, inflamed, or scarred bile duct tissue, as this guarantees failure 1
• Avoid end-to-end bile duct anastomosis when tissue loss is present, as this is associated with increased failure rates compared to hepaticojejunostomy 1
• Do not attempt repair of complex vasculobiliary injuries intraoperatively, even by expert HPB surgeons—these should be delayed 1, 2
• Ensure adequate exposure and mobilization to create a truly tension-free anastomosis, as tension is a major cause of stricture formation 1