What's in a name?
Hilo-Jejunostomy, not Hepatico-Jejunostomy,
for Post Cholecystectomy Iatrogenic Benign Biliary Stricture
Vinay K. Kapoor*
Professor of Surgical Gastroenterology, Sanjay Gandhi Post-graduate Institute of Medical Sciences (SGPGIMS), Lucknow 226014 UP, India
Professor of Surgical Gastroenterology, Sanjay Gandhi Post-graduate Institute of Medical Sciences (SGPGIMS), Lucknow
226014 UP, India, E-mail:
Received: 08 April, 2016; Accepted: 29 June, 2016; Published: 10 July, 2016
Gall stone disease is common all over the world;
cholecystectomy is one of the commonest operations performed
by a general surgeon. Bile duct injury is a not uncommon
complication of cholecystectomy and the risk of bile duct injury
is at least 2-3 times more during laparoscopic than during open
cholecystectomy, the incidence being around 0.5%.
Bile duct injury during cholecystectomy may result in an
iatrogenic benign biliary stricture. Benign biliary strictures are
classified from Bismuth Type I to Type V depending upon the
length of the common hepatic duct stump and patency of the
biliary ductal confluence as follows
Type I Common hepatic duct stump >2 cm
Type II Common hepatic duct stump <2 cm
Type III No common hepatic duct stump but biliary
ductal confluence patent
Type IV Biliary ductal confluence not patent (right and
left hepatic ducts separated)
Type V Stricture involving an aberrant duct
The gold standard of management of benign biliary stricture is
surgical repair in the form of a biliary enteric anastomosis. Biliary
enteric anastomosis for benign biliary stricture, irrespective of
its Bismuth Type, should be at the hilum of the liver. The hilar
plate needs to be lowered in order to expose the extra-hepatic
horizontal part of the left hepatic duct at the base of the quadrate
lobe (segment IV). The ductotomy should extend across the
hilum (biliary ductal confluence) into the left hepatic duct- the
Hepp Couinaud approach .
We want to suggest a new name for the biliary-enteric
anastomosis performed for benign biliary stricture.
Right and left hepatic ducts unite at the hilum of the liver to
form the common hepatic duct which is joined by the cystic duct and continues as the common bile duct. Extrahepatic bile ducts,
common hepatic duct and common bile duct, receive their blood
supply from below from the gastroduodenal artery or the proper
hepatic artery  via two longitudinal arteries which run along
the length of the bile duct at 3 and 9'0 clock positions and from
above from the caudate artery and the medial subsegmental
artery of segment IV via an arterial network present in the hilum
of the liver . In the case of a bile duct injury, the blood supply
from below has been interrupted and the only blood supply to the
bile ducts is from the hilum. For this reason, even in a Bismuth
Type I or II BBS, the common hepatic duct stump though present
has poor blood supply and is not suitable for anastomosis.
The biliary-enteric anastomosis for benign biliary stricture is
thus different from other biliary-enteric anastomosis as follows:
i. Choledocho-duodenostomy (Figure 1) for stone disease
where the infra-cystic supra-duodenal part of the
common bile duct is anastomosed to the first part of the
ii. Hepatico-jejunostomy (Figure 2) in pancreatoduodenectomy
or after excision of a choledochal cyst where the
common hepatic duct above the cystic duct but below the
hilum is anastomosed to a Roux-en-Y loop of jejunum.
iii. Porto-enterostomy (Figure 3) for extra-hepatic biliary
atresia where the liver capsule around the porta hepatis
containing openings of multiple intrahepatic bile ducts is
anastomosed to a Roux-en-Y loop of jejunum.
iv. Cholangio-jejunostomy (Figure 4) for high biliary block
e.g. hilar cholangiocarcinoma  or gall bladder cancer
 where an intra-hepatic bile duct, most commonly
of segment III, is anastomosed to a Roux-en-Y loop of
v. Longmire procedure, again for the high biliary block where
a part of the left lateral segment of the liver is resected
Figure 1: Choledocho-duodenostomy-side to side anastomosis between
the infra-cystic supra-duodenal part of the common bile duct
(short arrow) and the first part of the duodenum (long arrow).
Figure 2: Hepatico-jejunostomy-end to side anastomosis between the
common hepatic duct (short arrow) above the cystic duct but below the
hilum and a Roux-en-Y loop of jejunum (long arrow).
Figure 3: Porto-enterostomy -porta hepatis has been dissected and vessels
have been looped; no bile ducts are seen-the liver capsule around the
porta hepatis (short arrow) containing unseen openings of multiple small
intra-hepatic bile ducts will be anastomosed to a Roux-en-Y loop of jejunum.
Picture courtesy Prof Richa Lal Pediatric Surgery SGPGIMS Lucknow
so that the intrahepatic ducts of segments II and III are
exposed; the cut surface of the liver is then anastomosed
to a Roux-en-Y loop of jejunum. In a modification, the
exposed intrahepatic ducts are anastomosed to the Rouxen-
Y loop of jejunum .
Cholangiocarcinoma arising from the bile ducts at the
hilum (confluence of right and left hepatic ducts) is called hilar cholangiocarcinoma. Following the same nomenclature,
we propose that the biliary-enteric anastomosis for postcholecystectomy
benign biliary stricture which should be
performed at the hilum (confluence of right and left hepatic ducts
and extending into the left hepatic duct) should be called 'hilojejunostomy'
(Figure 5) to differentiate it from other biliaryenteric
anastomoses including hepaticojejunostomy.
Figure 4: Cholangio-jejunostomy -the left forceps points to the left side
of the base of the falciform (round) ligament where the intra-hepatic
bile duct of segment III (short arrow) will be found and will be anastomosed
to a Roux-en-Y loop of jejunum.
Figure 5: Hilo-jejunostomy-side to side biliary enteric anastomosis at
the hilum (confluence of right and left hepatic ducts and extending into
the left hepatic duct)-openings of both right and left hepatic ducts are
seen (short arrow).
Figure 6: Diagrammatic representation of the sites of anastomosis: 1
Choledocho-duodenostomy, 2 Hepatico-jejunostomy, 3 Porto-enterostomy,
4 Cholangio-jejunostomy, 5 Hilo-jejunostomy.
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