Laparoscopic reconstruction of the extrahepatic bile duct using a jejunal tube: an innovative, more physiological and anatomical technique for biliodigestive derivation
A 41-year-old man was referred to the University Hospital, Department of Digestive Surgery, Triangulo Mineiro Federal University, with jaundice, choluria and fecal hypocholia. The patient had undergone laparotomic cholecystectomy 2 days earlier. Upon physical examination, the patient was in good general health, pale (1+/4+), hydrated, jaundiced (1+/4+) and afebrile. The abdomen was slightly tender and bowel sounds were reduced. Abdominal ultrasonography performed on admission demonstrated dilatation of the intrahepatic bile ducts and only the proximal portion of the common hepatic duct was seen. The patient presented hyperbilirubinemia. Gamma-glutamyl transferase (γ-GT) was 235.4 U/L, alkaline phosphatase 187.6 U/L, aspartate aminotransferase (AST) 183.4 U/L and alanine aminotransferase (ALT) 485.7 U/L.\nThe patient was submitted to surgical intervention. Inspection showed a small fistula (probably the duct of Luschka []) in the gallbladder bed, the common hepatic duct was sectioned with loss of substance between segments, and the proximal and distal stumps were ligated with cotton suture. Next, catheterization of the fistula in the duct of the gallbladder bed was performed with a No. 4 Levine catheter. Cholangiography showed moderate dilatation of the intrahepatic bile duct and a sudden obstruction in the common hepatic duct 1 cm from the confluence of the hepatic ducts, corresponding to bile duct injury classified as Bismuth II (Fig. ).\nThe intervention chosen was reconstruction of the bile duct by interposition of a pedicled jejunal segment between the hepatic duct bifurcation and duodenum. A 5-cm segment was cut from the jejunal loop at a distance of 40 cm from Treitz angle (Fig. ) and divided into two segments of 2.5 cm, each containing their respective vascular pedicles (Fig. ).\nThe mesenteric and antimesenteric borders of the two segments were cut longitudinally (Fig. ), promoting jejunal detubularization and forming two separate pedicled rectangles (Fig. ). Side-to-side anastomosis proximal to the pedicle was performed with 3-0 continuous sutures of polyglactin 910 (Vicryl®) on a single plane.\nTransverse retubularization of the loop was performed with a No. 12 Levine catheter as a mold. A 21-cm tube was created using 3-0 continuous sutures of polyglactin 910 (Vicryl®) (Figs and ). The size of the tube was reduced to 15 cm by resection of the distal ends by ∼3 cm. A transmesocolic passage for the tube was created and an entero-enteral anastomosis was performed for reconstruction of jejunal transit.\nThe tube was formed and the common hepatic duct was anastomosed with interrupted 3-0 polypropylene (Prolene®) sutures. A longitudinal incision of ∼3 cm was made in the second portion of the duodenum, comprising the serous and muscle layers and preserving the mucosa.\nThe Levine catheter was maintained and exteriorized through the opening in the duodenum for subsequent radiological control and external biliary drainage into the duodenum.\nMagnetic resonance cholangiography performed 45 months after surgery showed a functioning tube (Fig. ). The patient continues to be anicteric and laboratory tests are normal.