Ann Hepatobiliary Pancreat Surg.  2020 Nov;24(4):513-517. 10.14701/ahbps.2020.24.4.513.

Cystic duct patch closure of remnant bile duct in living donor hepatectomy when primary closure is difficult: An easy solution

• Gupta S
• Kandagaddala R
• Agarwal S
• Dey R
• Naganathan S
• Varshney P
• Patil N

• KMID: 2508861
• DOI: http://doi.org/10.14701/ahbps.2020.24.4.513

Abstract

Backgrounds/Aims
In living donor hepatectomy, hepatic duct division is a crucial step and often a technical challenge, with the aim of obtaining a good hepatic duct for anastomosis in the recipient and an adequate stump in the donor for closure. Very rarely, after duct division, the remaining stump may not be adequate for primary closure. In such a difficult situation, the options would be either to close stump transversely or a Roux-en-Y Hepaticojejunostomy.
Methods
We describe a novel surgical technique of “Cystic duct patch repair”, utilizing the available local tissues for closure of bile duct wall.
Results
Two year follow up of this technique showed satisfactory results with no evidence of stricture and normal liver functions.
Conclusions
In living donor hepatectomy, “Cystic duct patch closure” may be used if the post closure cholangiogram is not satisfactory. Although the best method is prevention by ensuring a stump for closure, very rarely this error can occur and can be sorted by cystic duct patch repair.

Keyword

Cystic duct patch; Living donor hepatectomy; Donor bile duct repair

Figure

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  Fig. 1 Transcystic cholangiogram after primary closure showing narrowing in the CHD at right duct transection site.

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  Fig. 2 Pictorial representation of the technique. (A) Normal line of “Right hepatic duct transection.” (B) “Right hepatic duct stump closure” and normal left and common hepatic ducts without narrowing. (C) “Right hepatic duct transection” more towards the confluence or left hepatic duct (D) demonstrating “Right hepatic duct stump closure” resulting in “narrowed common hepatic duct.” (E) Cystic duct stump after removal of the catheter, (F) cystic duct stump used as a patch closure of the narrowed common hepatic duct at right hepatic duct transection site, (G) common hepatic duct contour after “cystic duct stump and Right hepatic duct stump anastomosis.”

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  Fig. 3 Intraoperative pictures of “Cystic duct patch–CHD anastomosis.”

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  Fig. 4 Check cholangiogram following “Cystic duct patch repair.”

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  Fig. 5 Follow up MRCP at 2 years, showing no evidence of any stricture in the donor bile duct. (A) Asterisk: cystic duct patch, long arrow: cystic duct, short arrow: cystic duct-CHD junction, arrow head: CHD. (B) MRI: coronal section demonstrating CBD with no stricture or dilatation. (C) MRI: coronal section at different level demonstrating cystic duct patch.

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