Results of a new strategy for reconstruction of biliary injuries having anisolated right-sided component

Poor results after repair of biliary injuries are most common when injuries are above the bifurcation of the left and right hepatic ducts or involve a berrant ducts. We have developed a novel approach to the right-sided compon ent of such injuries. Preoperatively all isolated sections of the biliary t ree are intubated percutaneously. At surgery the left duct is found by the Hepp-Couinaud approach. Dissection is continued to the right, staying withi n the coronal plane of the left hepatic duct, and continuing across the gal lbladder plate into segment 5 between the hepatic parenchyma and the Waller ian sheath of the right portal pedicle. Hepatic parenchyma, anterior to the sheath, is resected. After a length of portal pedicle is exposed, right-si ded bile ducts are opened on their anterior surface, using the percutaneous transhepatic stents as a guide, and hepaticojejunostomy is performed. Twen ty-three patients were treated from May 1993 to February 1999. Injury types and (number of patients) were as Follows: B (n = 2), C (n = 5), E4 (n = 10 ), and E5 (n = 6). There were no perioperative deaths. Follow-up ranged fro m 8 months to 7 years (median 3 years). There have been no cases of restric ture, reoperation, or jaundice, and no interventional procedures. Serum bil irubin is normal in all patients. Alkaline phosphatase is normal or less th an two times the normal value in 21 of 22 living patients. This novel appro ach brings the benefits of the Hepp-Couinaud approach to the right hepatic ducts. Very satisfactory results were obtained in the most severe types of biliary injury.