Hepaticojejunostomy, Choledochoduodenostomy, and Whipple's Procedure

A comprehensive surgical reference with viva Q&A

PART 1: CHOLEDOCHODUODENOSTOMY (CDD)

Anatomy Relevant to CDD

• Supraduodenal common bile duct (CBD): runs in the free edge of the hepatoduodenal ligament, anterior to the portal vein, medial to the hepatic artery
• The CBD measures 6-8 mm normally; a duct >15 mm is considered dilated and is the minimum required for CDD
• The postbulbar (first part) duodenum lies immediately adjacent, forming the natural anastomotic partner
• The Kocher maneuver (mobilization of duodenum off the retroperitoneum) is essential to bring the duodenum into proximity with the CBD without tension

Indications

• CBD diameter >15 mm (ideally >20 mm) from benign obstruction - Fischer's Mastery of Surgery
• Recurrent CBD stones (>15 stones, intrahepatic stones, or primary CBD stones) after failed endoscopic sphincterotomy
• Large duct syndrome with biliary stasis and stone formation
• Strictures from chronic pancreatitis (distal, benign)
• Failure to clear distal CBD obstruction during open CBD exploration
• Historical indication: ~1% of all biliary operations; mean patient age 61 years

Contraindications

• CBD diameter <15 mm (risk of sump syndrome and stricture)
• Malignant distal obstruction - these require Roux-en-Y hepaticojejunostomy
• Acute or chronic pancreatitis from ductal obstruction (CDD does not address the causative problem)
• Impacted distal stone with pancreatitis (relative)

Operative Steps

1. Cholecystectomy first; expose CBD by incising overlying peritoneum
2. Extended Kocher maneuver - mobilize duodenum and pancreatic head medially; this is mandatory to allow a tension-free anastomosis
3. Longitudinal choledochotomy - 2.0 to 2.5 cm in the supraduodenal CBD, usually extending to the common hepatic duct
4. Complete CBD exploration; confirm and remove stones
5. Duodenotomy - longitudinal incision in the postbulbar duodenum, slightly smaller than the planned stomal caliber (elasticity compensates); the incisions should be side-to-side
6. Stay sutures placed at the corners of the planned anastomosis
7. Posterior row - interrupted 4-0 absorbable suture (polyglycolic acid), knots on the inside of the anastomosis
8. A bisecting suture placed at the lower end of the choledochotomy meets the midpoint of the duodenal incision
9. Anterior row - sutures placed without tying, held with traction to prevent inadvertent closure of the posterior wall; then tied medial to lateral
10. Single-layer closure only - a second layer would narrow the anastomotic orifice
11. Closed suction drain placed posterior to the anastomosis

Postoperative Care

• Clear liquid diet advancing to solid food as tolerated
• Drain removed when output is non-bilious and low
• Monitor for bleeding, DVT, PE, surgical site infection

Complications

PART 2: HEPATICOJEJUNOSTOMY (HJ) / ROUX-EN-Y HJ

Anatomy

• The anastomosis is made at the hepatic duct confluence or above (left/right hepatic ducts when needed)
• Key anatomical landmark: the hepatic plate (hilar plate) - lowered to expose the left hepatic duct for high injuries
• The Roux limb of jejunum is brought up in a retrocolic, retrogastric position (most common) or antecolic
• The right hepatic artery often crosses anterior to the common hepatic duct - must be identified and preserved
• Bismuth classification of bile duct injuries determines the level of the anastomosis

Indications

Malignant

• Unresectable periampullary/pancreatic head cancer causing biliary obstruction - palliative bypass ("double bypass" when combined with gastroenterostomy)
• Hilar cholangiocarcinoma (Klatskin tumor)
• Failed or recurrent biliary stenting causing cholangitis

Benign

• Bile duct injury (BDI) during cholecystectomy - incidence 0.4%-0.6%; HJ is the mainstay of surgical repair; index repair is most critical and must be done by experienced HPB surgeon
• Choledochal cyst resection (Type I, IV)
• Biliary stricture from chronic pancreatitis (proximal/mid-CBD)
• Recurrent pyogenic cholangitis
• Primary sclerosing cholangitis (selected cases)
• Primary biliary stone disease
• Part of the Whipple reconstruction

Preoperative Planning

• LFTs, coagulation, albumin - to detect chronic liver disease and coagulopathy
• Biliary imaging: MRCP, ERCP, PTC
• Consider preoperative biliary drainage for profound jaundice
• Assess for concomitant vascular injury (right hepatic artery) in BDI cases
• Early repair preferred (within 2 weeks) if no biloma or vascular injury; otherwise percutaneous drainage + delayed repair

Operative Steps

1. Diagnostic laparoscopy for malignant cases
2. Incision: right subcostal or bilateral subcostal (rooftop)
3. Hepatoduodenal ligament dissection - identify CBD, portal vein, hepatic artery
4. Hilar plate lowering if needed (for high injuries - expose left hepatic duct at base of segment 4)
5. Bile duct transection - at appropriate level (above injury/obstruction); spatulate the duct opening
6. Roux-en-Y construction: divide jejunum 30-40 cm from the ligament of Treitz; create Roux limb of 60-70 cm; restore bowel continuity with jejuno-jejunostomy; bring limb retrocolic
7. End-to-side hepaticojejunostomy: mucosa-to-mucosa anastomosis using interrupted 4-0 or 5-0 absorbable sutures (PDS); posterior row first, then anterior row; single-layer preferred
8. For ducts >8 mm - direct anastomosis; for small ducts (<5 mm) - stented anastomosis with transhepatic stent
9. Abdominal drain near the anastomosis

Specific Considerations for Bile Duct Injury Repair

• Best outcomes: preserved biliary confluence + immediate repair + no vascular injury
• Do NOT perform HJ if right hepatic artery is compromised without vascular repair first
• Bismuth-Strasberg Type E4/E5 injuries require bilateral hepatic duct anastomoses or left hepaticojejunostomy

Complications

PART 3: WHIPPLE'S PROCEDURE (Pancreaticoduodenectomy)

Anatomy

Structures removed (standard Whipple):

• Pancreatic head and uncinate process
• Entire duodenum (1st-4th parts)
• Gallbladder and common bile duct
• Gastric antrum (classical Whipple); pylorus preserved in pylorus-preserving PD (PPPD)
• Regional lymph nodes

Key vascular anatomy:

• Superior mesenteric vein (SMV) - runs posterior to neck of pancreas, joins portal vein behind neck
• Portal vein - courses posterior to pancreatic neck; a "tunnel" anterior to the portal vein between it and the pancreatic neck is established to assess resectability
• Gastroduodenal artery (GDA) - arises from common hepatic artery; ligated during resection; stump covered with round ligament pedicle
• Superior mesenteric artery (SMA) - to the right of the SMV; runs in the root of mesentery; the uncinate process is separated from its right side
• Replaced right hepatic artery (present in 15-20%) - arises from SMA, runs posterior to the CBD; must be identified and preserved
• Middle colic vein - enters SMV anteriorly; often divided during step 1

Reconstruction anastomoses (3 required):

1. Pancreaticojejunostomy or pancreaticogastrostomy
2. Hepaticojejunostomy (biliary)
3. Gastrojejunostomy or duodenojejunostomy (PPPD)

Indications

Malignant (primary)

• Pancreatic ductal adenocarcinoma (head/uncinate) - most common indication
• Ampullary carcinoma
• Distal cholangiocarcinoma (lower 1/3 bile duct)
• Duodenal adenocarcinoma
• Cystic pancreatic neoplasms (IPMN, MCN with malignant features, solid pseudopapillary tumor)
• Neuroendocrine tumor of pancreatic head

Benign (selected)

• Chronic pancreatitis with painful ductal obstruction (when Frey/Beger procedures are not applicable)
• Duodenal trauma
• Bile duct injury at the level of pancreatic head

Preoperative Assessment

• CT chest/abdomen/pelvis (pancreatic protocol) - define tumor, vascular involvement
• Diagnostic laparoscopy at the time of surgery - up to 10% have occult metastatic disease
• CA 19-9, CEA
• ERCP/biliary stenting if significant jaundice (bilirubin >10-15 mg/dL)

Six-Step Operative Technique (Current Surgical Therapy / Sabiston)

Step 1 - Define the infrapancreatic SMV

• Elevate greater omentum from transverse colon
• Mobilize hepatic flexure to duodenum
• Enter lesser sac; incise peritoneum along inferior border of pancreas medial to lateral
• Expose infrapancreatic SMV and junction of middle colic vein with SMV
• Middle colic vein divided or common trunk with gastroepiploic vein managed

Step 2 - Kocher maneuver / mobilize duodenum and pancreatic head

• Start at third portion of duodenum, identifying the IVC
• Mobilize duodenum and pancreatic head medially to the left renal vein and lateral aspect of aorta
• Divide leaf of visceral peritoneum posterior to mesenteric vessels (contains lymphatics - ligate)
• Releases tissue from 3rd duodenum to foramen of Winslow - facilitates SMA dissection

Step 3 - Portal dissection / superior border of pancreatic head

• Identify common hepatic artery; remove hepatic artery lymph node
• Identify GDA and proper hepatic artery
• Ligate small right gastric artery (anterior to GDA)
• Cholecystectomy (top-down, identifying cystic duct-CBD junction)
• Identify and preserve replaced right hepatic artery if present (runs posterior to CBD)
• Divide GDA between ligatures (test-clamp first to confirm adequate hepatic flow); stump covered with round ligament pedicle at end of case
• Establish tunnel anterior to portal vein posterior to pancreatic neck - confirms resectability

Step 4 - Divide stomach or duodenum

• Classical Whipple: divide stomach at antrum (60% gastric remnant) using linear stapler
• PPPD: divide duodenum 2 cm distal to pylorus
• Divide proximal jejunum 10-15 cm distal to the ligament of Treitz
• Pass the right colon mesentery under the superior mesenteric vessels to bring the jejunum into the right upper quadrant

Step 5 - Divide pancreatic neck

• Pancreatic neck divided over the portal vein using electrocautery; send frozen section of pancreatic neck margin
• Full exposure of portal vein, SMV, splenic vein confluence
• Careful identification and ligation of venous branches from pancreatic head/uncinate into right lateral SMV/portal vein: superior and inferior pancreaticoduodenal veins, right gastroepiploic vein, anomalous branches

Step 6 - SMA dissection / uncinate process

• Separate uncinate process from right side of SMA
• "Artery-first" approach: early identification of SMA from posterior or medial allows assessment of SMA margin (most common site of R1 resection)
• The SMA is the boundary between the uncinate process (to resect) and the proximal jejunum mesentery (to preserve)

Reconstruction

• End-to-side or end-to-end; invagination (dunking) or duct-to-mucosa technique
• Duct-to-mucosa preferred for dilated ducts (>5 mm); invagination for soft pancreas/small duct
• Two-layer closure with interrupted sutures
• Surgeon's preference: some use pancreaticogastrostomy (PG) as alternative

• End-to-side, 10-15 cm distal to PJ, single-layer interrupted absorbable sutures
• Mucosa-to-mucosa

• 45-60 cm distal to HJ on the Roux limb (antecolic most common)
• Two-layer hand-sewn or stapled anastomosis

Complications

Procedure-Specific (ISGPS Definitions)

General Complications

VIVA QUESTIONS AND ANSWERS

Choledochoduodenostomy

Hepaticojejunostomy

• Associated biloma requiring drainage
• Associated vascular injury (right hepatic artery) - requiring repair first or interval for collateral formation
• Inflammatory/septic field - biliary drainage + delayed repair after 6-8 weeks preferred

Whipple's Procedure

1. Pancreaticojejunostomy (or pancreaticogastrostomy) - most proximal
2. Hepaticojejunostomy - 10-15 cm distal
3. Gastrojejunostomy (or duodenojejunostomy in PPPD) - 45-60 cm distal

• Grade A (biochemical leak): amylase in drain >3x ULN, no clinical impact, treated conservatively
• Grade B (CR-POPF): requires change in management (antibiotics, prolonged drainage, IR drainage)
• Grade C (CR-POPF): requires re-operation or results in death

• Soft pancreatic texture (most important)
• Small pancreatic duct diameter (<3 mm)
• Fatty/fibrofatty pancreas (high BMI)
• High intraoperative blood loss (>1000 mL)
• Pathology (non-pancreatic cancer / IPMN carry higher risk than PDAC due to soft gland)

• Grade A: NGT until POD7 or reinsertion after POD3
• Grade B: NGT until POD14
• Grade C: NGT >POD14 or re-institution after removal Treatment: prokinetics (metoclopramide, erythromycin), NGT, TPN if prolonged; underlying POPF or intra-abdominal collection must be excluded.

• Late PPH is the most dangerous - a sentinel bleed (hematemesis or drain blood) from GDA stump pseudoaneurysm precedes catastrophic hemorrhage
• Management: urgent CT angiography followed by interventional radiology angioembolization; surgery reserved for failure of IR