For a conventional hepaticojejunostomy for example to reconstruct after a pancreaticoduodenectomy, I use a 5/0 running pds suture most of the time, unless it is a bile duct injury or after extended liver resection on to a small duct on the cut liver surface in which case I usually do an interupted either 5/0 or 4/0 pds anastomosis as described by Blumgart. I never use a stent across the anastomosis.

Thank you Stephen, actually I follow the similar strategy, except that when I have concerns about running suture for the entire anastomosis I do only front row with interrupted sutures. It is easier and I am interested whether others also do the same, or prefer to create always the entire anostomosis in one fashion.

Especially for small ducts we prefer 6-0 interuppted PDS suture with knots tied outside. Small internal stent is optional.

Thanks George. Knots outside are mandatory. But whether you perform interrupted suturing only in pediatric population, where growth is expected and there is no doubt that interrupted is better, or do the same also in adults?

For small ducts (1 cm), same principles, running 5-0 PDS, no stent.

In all cases, be sure of ductal anatomy with preop cholangiography, MRCP, and/or intraop exploration of ducts with probe. Don't miss a low insertion of a right posterior sectoral duct.

Thank you Sean,

You mentioned the basic principles to maintain. However I am not aware for a study which compares different techniques for bilioenterostomy. As many surgeons are satisfied with the techniques they used it does not seems such a study to be conducted. I did not find any evidence about superiority of one technique over another. But when residents observe different thinks the usually now ask about the evidence:) Do you have any evidence to share?

For a hepaticojejunostomy or cholangiojejunostomy for example to reconstruct after bile duct injury or hepatectomy, I usually use a 6/0 or 5/0 PDS to perform an interupted anastomosis as described by Blumgart .The knots of posterior row tied inside. I use transanastomotic stent when I can not do duct –to-mucosa anastomosis.

Dear Benham,

I am afraid that I will feel uncomfortable with ties within the bile duct for at least 6 moths, as is the case with PDS. And to the best of my knowledge Blumgart never proposed to tie posterior row sutures inside the anastomosis.

I always use 4-0 or 5-0 PDS or Maxon monofilament suture, doing a running suture in posterior wall, and a single stitch row, for the anterior wall

I previously used a double line running suture in PDS 5/0 or 6/0. Now I´m mostly doing single line interrupted suture 5 or 6/0 PDS.

As I suspected there are various preferred techniques, and I am sure that all of you do not need to change them. So does anybody think that his/her technique is superior over others? Or you just use the technique which is comfortable for you?

I think is just question of preferences

I agree with you Marco. Could you share how you moved from two- to single-layer technique?

Hi Alexander, Hope you keeping well.

Obviously many different ways are all good in the hand of a good surgeon.

Personally I prefer, 4/0 PDS on round body needle, interrupted. However if the duct is really small I would use 5/0.

If I am doing it laparoscopically, I do continuous for the posterior wall and interrupted for the anterior, this is technically easier.

Re stent: is small risky ducts or repair for small bile duct injury; I may consider a t-tube. If the duct is not very small but the risk is average I do use a 4-5 cm trans anastomotic piece of T tube fixed with vicryl 5/0 .

Looking forward to see you again in Southampton

Mo

Hi Mo!!!

It is wonderful to meet you even virtually :)

Thank you for sharing your expertise, and as I see there are small differences between techniques used by surgeons worldwide.

Let me to share with the audience that you a leading expert, organizing a remarkable laparoscopic HPB course at Southampton General Hospital. To the best of my knowledge and experience it is the best one, and invaluable for the surgeon wishing to start a program or to improve his skills in major laparoscopic liver and pancreatic surgery.

Hope to see you again in the nearest future, in the meantime please accept all the best wishes for you and Mona from Ani and me.

Alex

Many thanks Alex for the nice words. Best regards also to Ani from me and Mona

Running suture, PDS 5-6/0, no stents

Interrupted PDS 5/0 or 6/0 suture, often without stent

I use interrupted PDS sutures, 4-0, 5-0 or 6-0 according to the size of the duct, without any stent, the best parachute technique originally described by Couinaud.

No stent. Interrupted vycryl 5-0 sutures. The less sutures the less ischemia and leak. Drain the area.

I use interrupted PDS or Vicryl sutures 5/0 or 6/0 according to the size of the duct. I do use silastic stents in very small intrahepatic ducts

We use Interrupted vycryl 4-0 sutures and 3-0 sutures. Without using stents. Single-row choledochojejunoanastomosis is formed with 7-8 cm indent from intestine stump. Choledochojejunoanastomosis is invaginated into jejunum by means of two semi-purse-string serous-muscular sutures. Serous membrane of intestine is fixed to choledoch wall with separate interrupted sutures. Region of formed anastomosis is covered from the front with stump of intestine, fixed to anterior wall of intestine by means of interrupted serous-muscular sutures more laterally than zone of anastomosis and to choledoch wall on line of its adjoining duct with several interrupted sutures. We have patented this technique. If you want I can send you description by mail.

Dear Evgeny, I am interested did you compare this technique in a randomized setting to prove that it is really beneficial in some points? Or you just prefer it empirically?

Dear Alexander, we'ed operated 21 patient for 4 year (from 2009 till now) with this technique. It's not experiment on paper)))

Dear Evgeny thank you for your answer. My question was about the evidence. But I see that with 5 procedures yearly it will be impossible for you to start randomized trial.

Thank you Alexandr! We make x-rays with contrast (urografin) after few month after operation, it show absence of the reflux to the bile ducts.

If Hepato-choledochus are large, then we make a running suture.If it is small then we make intterupted suture. Most of time with Vascufil 4-0, else with monocryl 4-0.

We never stent.

In case of large dilated duct(s): running suture PDS 5-0.

In case of non-dilated duct(s): interrupted sutures PDS 5-0: knots on the outside, short internal stents ( baby gastric feeding tube cut to length (5-8cm))

Seldom drains, only in case of ascites as in OLTx

4-0 or 5-0 PDS or Maxon suture. Running suture in posterior wall, and a single stitch row, for the anterior wall. No stent.

PDS 5/O interrupted, every suture taken under vision, 1st suture taken in the middle anterior wall jejunal side to help retraction of jejunal anterior wall. followed by interrupted sutures posterior wall & parachuting the posterior wall then completion of anterior wall similarly. No stent but drain placed (closed suction).

Interupted vicryl 3/0 with stent and mucosal grafting inside the ducts

In cases of a large bile duct I use a running suture of the posterior wall and interrupted sutures of the front wall. Suture material is PDS or Monocryl (monofilament sutures). I use no stenting normally. In cases of a small bile duct I enlarge the anastomotic surface/length by splitting the frontwall of the bile duct and using a triangular incision of the small intestine as it was described by Güthgemann.

For pediatric living related liver transplant, in very small left bile ducts, we perform an interrupted anterior wall on the bile duct with double needle 6/0 PDS. We take all the stitches in an orderly fashion. Then we perform the posterior wall with continuous 5/0 or 6/0 prolene and then we complete the anterior wall on the bowel. No stent. All the knots outside.

From 2009 we have performed 7 cases with no bile duct complications. I also use a similar technique for Kasai procedures and open choledochal cysts in which we perform a high anastomosis, in normal non-dilated hepatic ducts (not in the cysts as some people do).

Regards,

JC.

End to side, submucosal, single layer hepaticojejunostomy with interrupted absorbable (3/0 to 5/0) sutures, knots inside, no routine use of transanastomotic stents (only if the duct is very tiny just for postopoperative cholangio, max. stay 2 wks).

Hepaticojejunostomy is usually done with PDS 4/0 or Monocryl 4/0. End to side anastomosis is the preferred mode with submucosal single layer technique in most cases. Interrupted suturing in most cases except large bile duct where continuous suturing is very safe. Trans-anastomotic stents is usually avoided except narrow anastomotic site. Drain is placed always.

I agree with answer of Dr Satyendra Tiwari and I perform the same way but even for large ducts only posterior sutures are continuous but anterior sutures are interrupted.

George Chatzoulis:In case that someone could stending the anastomosis,what kind of stend must be used?. A 6 cm self retaining internal stend with vicryl anchored,an external internal stend from the bowell and abdominal wall,or an external internal stend from the liver parenchyma and abominal wall and remove it in a month?Even if I favored the self retaining stends some colleague tell the possibility of stend moving inside the liver parenchyma.

I perform HJ in dilated system using 4-0/5-0 PDS interrupted sutures both anterior and posterior layer, using the parachute technique. In nondilated system in transplant scenario it is using either 5-0/6-0 PDS interrupted again, parachute technique under vision, no stents.

I would selectively use stents(silicon/latex) in patients who have cholangitis, have infected thick bile(can be used for flushing in the postop period), in patients who have intrahepatic stones. These stents are external stents and generally would perform cholangiogram after 3 weeks and take a decision to remove. Might require extended periods of stenting with intrahepatic stones etc.

In the setting of dilated duct as in biliary obstrction i used to do bilirentric anastomosis with 3/0 interrupted with purachotee technique ,without stents , in setting of non dilated duct i used to put biliary stents for support the anastomosis in early postoperative period and for radiological purpose ,in setting of transplant i used 6/0 prolene with biliary stents .

I agree that in large ducts ,running suture for post and interrupted for ant. without stent but for small duct i prefer interrupted absorbable 5/0 or 6/0 sutures like PDS and if use prolene I try to put ties out of lumen

End to side PDS 4/0. If more than 5 mm continue in posterior layer and interrupted in anterior layer. If less than 5 mm interrupted sutures in both layers. Technique described by Blumgart and co-workers in several books and papers. About stent it depends: size, diagnosis and other conditions (cholangitis,..) I leave in place or take out

We use 4/0 adsorbable continuos suture almost always and we use a T tube when the duct is thin. Two layer for the posterior wall and simple extra-mucosal for the anterior surface, knots outside always. When we placed a T tube we do a cholangiogram 4 weeks after the procedure.

For end-to-side anastomosis, we use Biosyn 4/0 single layer interrupted sutures. I believe running suture acceptable when the size of common duct is beyond 1.5 cm. Stent are placed when CBD is less than 1 cm and, whatever the size, when bile is infected (cholangitis) or liver shows signs of failure.

3/0 or 4/0 vicryl or PDS single ,interrupted mucosa to mucosal anastamosis, a small internal stent if the duct is small to prevent accidentally including the posterior wall.

In living donor liver transplantation, whether it's single or multiple ducts, I always use continuous, everting 6-0 prolene with the parachute technique for the posterior layer and interrupted 6-0 PDS for the anterior layer. I always use a transjejunal catheter (5F feeding tube) for each orifice in adults. In pediatric cases, I prefer interrupted 6-0 PDS for all layers and place an internal plastic stent. In adults, I never finish the case (in adults) without trans-catheter blue dye injection to rule out the leaks and intraoperative cholangiogram to verify the patency.

Large BD - PDS (4/0 or 5/0) running suture, no stent.

Small BD - loops, PDS (5/0 or 6/0), interrupted, no stent.

Best wishes 

4/0 or 5/0 PDS interrupted sutures.

No stent, except when previously there was a stent(for example ptc stent)

Always we use loops to perform a hepaticojejunostomy. For large bile hepatic ducts we use a 5/0 PDS running suture. In the case of small(

I use interrupted 5-0 PDS on ducts less than 10 mm. For larger ducts, running 5-0 PDS. No stents. Always use loupes. I culture the bile in patients with previously placed endoscopic or transhepatic stents.

I agree with DrMulvill.But in ducts

I normally use a 5/0 PDS to perform an interrupted anastomosis as (Blumgart), over a silastic stent in case narrow duct.