Choledochoduodenostomy Steps anatomy indications

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Choledochoduodenostomy

A side-to-side anastomosis between the common bile duct (CBD) and the first or second part of the duodenum, creating a biliary-enteric bypass that diverts bile flow around a distal CBD obstruction.

Relevant Anatomy

The procedure exploits the proximity of the supraduodenal CBD to the postbulbar duodenum:

Common bile duct: Runs in the hepatoduodenal ligament (anterior to portal vein, lateral to hepatic artery). The supraduodenal segment is the operative target - it is anterior and medial, accessible once the peritoneum over it is incised.
Postbulbar duodenum (D1-D2 junction): Lies immediately adjacent and slightly inferior/posterior to the CBD. The retroduodenal portion is the ideal anastomotic site.
Kocher maneuver: Mobilization of the duodenum medially by incising the lateral peritoneal reflection is mandatory - it brings the postbulbar duodenum into proximity with the CBD without tension, and allows full assessment of the distal duct.
Ductal blood supply: Runs at the 3 o'clock and 9 o'clock positions along the bile duct. Longitudinal choledochotomy (rather than transverse) avoids devascularization.
Hepatic artery: The right hepatic artery typically crosses behind the CBD - injury risk during duct exposure must be kept in mind.

Indications

Per Fischer's Mastery of Surgery, the indications are:

Indication	Detail
Dilated CBD from benign distal obstruction	CBD >2 cm indicates prolonged obstruction/loss of tone with biliary stasis; size alone is a relative indication
Failed endoscopic sphincterotomy	When ERCP has not cleared the obstruction - this is now the primary scenario since endoscopy is first-line
Recurrent CBD stones post-cholecystectomy	Not amenable to repeat endoscopic clearance
Numerous CBD stones	>15 stones, or intrahepatic stones
Primary CBD stones	Especially after a prior choledochotomy
Distal CBD stricture from chronic pancreatitis	Benign inflammatory stricture causing obstruction
Previous failed choledochotomy	Unable to clear the duct via exploration alone

Historically required in ~1% of all biliary operations; more common in elderly patients (mean age 61 years); ~60% are secondary procedures.

Contraindications

CBD diameter <15 mm - absolute contraindication (anastomosis too small; high risk of stricture and sump syndrome)
Malignant distal obstruction - these are better managed with Roux-en-Y hepatico- or choledochojejunostomy
Active pancreatitis (acute or chronic with obstruction) - does not address the underlying cause
Note: An impacted distal CBD stone was historically considered a contraindication (fear of pancreatitis), but series have shown the risk is quite low

Surgical Technique (Open)

Fig. 168.5 - Wide Kocher maneuver exposes the operative field:

Wide Kocher maneuver for CBD exploration and choledochoduodenostomy

Step-by-Step

Step 1 - Cholecystectomy Remove the gallbladder first to eliminate cystic duct reflux and decompression issues.

Step 2 - Expose the CBD Incise the overlying peritoneum of the hepatoduodenal ligament to expose the supraduodenal CBD.

Step 3 - Kocher maneuver Perform an extended Kocher maneuver - mobilize the duodenum and head of pancreas medially by incising the lateral peritoneal attachment. This is mandatory for adequate exposure and tension-free anastomosis.

Step 4 - Choledochotomy Open the CBD longitudinally in the supraduodenal location. If findings confirm the indication, extend the incision to 2.0-2.5 cm in the longitudinal axis (this typically extends up to the common hepatic duct). Complete the CBD exploration.

Fig 168.6A - Longitudinal 2.0-2.5 cm choledochotomy with planned duodenotomy

Fig 168.6A: The 2.0-2.5 cm longitudinal choledochotomy and the planned duodenotomy are shown.

Step 5 - Duodenotomy Make a longitudinal incision in the postbulbar duodenum. Make this incision slightly smaller than the planned stomal size, as duodenal elasticity can over-stretch and cause technical difficulty.

Step 6 - Stay sutures Place stay sutures at the corners of the planned choledochoduodenal anastomosis. These pass from the end of the duodenal incision. A bisecting suture is placed at the lower end of the choledochotomy at the midpoint of the adjacent duodenum.

Step 7 - Posterior row Place posterior row of sutures with 4-0 absorbable material (polyglycolic acid), with knots on the internal (luminal) aspect of the anastomosis.

Step 8 - Anterior row Place anterior row sutures without tying them. Traction holds them in place until all are placed - this prevents inadvertent closure of the posterior wall. Then tie them, starting at the medial side of the anastomosis.

Step 9 - Single layer only Do not use a double-layer closure - a second layer narrows the anastomotic orifice and defeats the purpose of a wide stoma.

Step 10 - Drain Place a closed suction drain posterior to the choledochoduodenostomy.

Laparoscopic Approach (Advanced)

Same principles apply; requires skilled intracorporeal suturing
A transverse (rather than longitudinal) choledochotomy can be used laparoscopically - but care must be taken not to devascularize the duct (blood supply runs medially and laterally)
Duodenum is incised longitudinally after Kocher maneuver; side-to-side anastomosis created with 4-0 polyglycolic acid interrupted sutures
Median operative time ~300 min (vs. ~180 min open) - Maingot's Abdominal Operations

Postoperative Care

Start with clear liquids, advance to solids as tolerated
Remove drain when output is non-bilious and low volume
Monitor for standard postoperative complications (bleeding, DVT, PE, SSI)

Complications

Complication	Notes
Anastomotic stricture	Long-term; manageable endoscopically
Sump syndrome	Debris/food collects in the distal blind-end CBD segment below the stoma - causes recurrent cholangitis. Managed with ERCP to clear the distal duct.
Anastomotic leak	Treat with IR-guided external drainage
Bile reflux / gastritis	More common than with Roux-en-Y hepaticojejunostomy

Major morbidity rate is ~11% (compared to ~20% for transduodenal sphincteroplasty).

CDD vs. Roux-en-Y Hepaticojejunostomy

CDD is simpler, faster, and avoids a jejunal limb
HJ is preferred for malignant obstruction and when the CBD is non-dilated
Both have better long-term patency than cholecystojejunostomy for benign disease
HJ has less risk of sump syndrome and bile reflux

Sources: Fischer's Mastery of Surgery, 8th ed., pp. 4655-4658; Maingot's Abdominal Operations, pp. 1105-1106; Mulholland and Greenfield's Surgery, 7th ed., p. 3080

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