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SURGICAL MANAGEMENT OF BILIARY DISEASES Jamie R.

Bellah, DVM, Diplomate ACVS


Affiliated Veterinary Specialists of Orange Park, P.A., Orange Park, Florida 32073 Anatomy Intralobular ducts form within the hepatic parenchyma from bile canaliculi. These become tributaries of the lobar ducts, which become the hepatic ducts as they emerge from the hepatic parenchyma. Once the hepatic ducts receive the cystic duct from the gall bladder the common bile duct travels within the lesser omentum to the duodenum. In the dog the common duct opens intraluminally near the center of the major duodenal papilla and the minor pancreatic duct opens next to the bile duct. The canine major pancreatic duct empties into the duodenum approximately 3 cm distal to the bile duct opening. This is in contrast to the cat, where the major pancreatic duct enters the duodenum along with the bile duct. Surgical Manipulation Exploration of the Extrahepatic Biliary System is often necessary to localize biliary obstruction or to determine the presence and type of disease. Gross inspection is followed by manual expression of the gall bladder, or, if not possible, aspiration with a syringe and 25 gauge needle. Cholecystotomy A cholecystotomy is commonly performed to allow tube exploration of the bile ducts, biopsy or removal of inspissated bile, choleliths or feline biliary flukes. Following emptying of the gall bladder, stay sutures are placed in the gall bladder wall and the gall bladder is penetrated with a scalpel. Care is taken to avoid spillage of bile into the abdomen by suction and packing towels around the surgical site prior to entering the lumen. A small soft catheter (3 to 8 French depending on the size of the dog or cat) is passed down the cystic duct into the common duct and into each divisional duct to determine the presence or absence of biliary obstruction. Following biliary duct exploration, a 50% dextrose solution is injected through the tube to estimate flow resistance through the common duct into the duodenum. An antimesenteric duodenotomy can be performed to allow direct visualization and assessment of the papilla if flow resistance seems excessive. This also allows retrograde insertion of a catheter to back flush stones or debris up the biliary track so it may be suctioned out or removed. Cholecystectomy Indications for cholecystectomy include treatment of cholelithiasis (rare), gall bladder neoplasia (rare), severe cholecystitis, or trauma. Biliary obstruction distal to the gall bladder should be bypassed by cholecystoduodenostomy not by cholecystectomy. The gall bladder is dissected bluntly from the surface of the liver, beginning at the fundus. Dissection is easier if the gall bladder is full. Gentle traction on the gall bladder aids dissection. Saline can be injected between the hepatic parenchyma and gall bladder serosa to aid identification of tissue planes. The dissection is continued until the cystic duct and cystic artery are identified. They are clamped, transected and singly or double ligated separately. Biliary-Enteric Anastomosis If trauma, inflammation or neoplasia has obstructed or disrupted the common bile duct a surgical procedure to redirect bile flow into the intestine is required. The preferred method is a cholecystoduodenostomy, but in situations where the duodenum cannot be moved to the gall bladder without tension, cholecystojejunostomy may be done. The gall bladder is bluntly dissected from its fossa and the gall bladder and duodenum are approximated with stay sutures. A 2-layer anastomosis is then performed, creating a stoma of at least 2.5-4 cm in length to allow adequate drainage of refluxed intestinal contents postoperatively. The serosal surfaces of the gall bladder and duodenum are approximated between the 2 stay sutures with a simple continuous pattern of 4-0 synthetic absorbable suture. A stab incision is made into the gall bladder

and the bile is aspirated. The incision is enlarged and an incision 0.5 cm smaller is made in the antimesenteric border of the duodenum. An elliptical piece of duodenal mucosa 2-3 mm wide is excised on the border of the duodenal incision, and the mucosal surface of the gall bladder is sutured to the mucosal surface of the duodenum in a simple continuous pattern. Sutures penetrate the submucosa and serosa of both organs to ensure adequate suture holding power. The near side serosal layer is then approximated and omentum is draped around the anastomosis after its patency and integrity are checked by injecting saline into the duodenal lumen. Postoperative antibiotics are indicated and complications after surgery include hemorrhage, biliary-enteric anastomotic dehiscence or breakdown, gall bladder injury (necrosis), and pancreatitis. Ascending septic cholecystitis and hepatitis may occur if the stoma diameter is inadequate. Bile Duct Lacerations Lacerations of the bile duct are difficult to diagnose. If bile peritonitis is diagnosed, exploration of the extrahepatic bile ducts is required. In some situation the damage to the bilary duct or ducts is not repairable, and a cholecystoduodenostomy is performed following double ligation of the bile duct on each side of the laceration. A direct end-to-end anastomosis of the bile duct may be attempted if the diameter is greater than 5 mm. Suture material size 4-0 or 5-0 synthetic absorbable suture. Postoperative stricture is common. Tube stents may be used prior to suturing to provide bile drainage during healing, minimize bile leakage and they can prevent stricture formation if left in long enough (up to 6 weeks). References: 1. Slatter, DH, ed. Textbook of Small Animal Surgery. Philadelphia:WB Saunders Co, 1985: p 794-827, p 1156-1174, p 1204-1218. 2. Bojrab, J, ed. Current Techniques in Small Animal Surgery. Philadelphia:JB Lippincott Co, 1990: p 291-308, p 544-548.

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