Roux-en-Y Choledochojejunostomy

Roux-en-Y Choledochojejunostomy

Introduction

Roux-en-Y Choledochojejunostomy is a surgical technique used to establish biliary-enteric continuity by anastomosing the common bile duct (CBD) to the jejunum in a Roux-en-Y configuration. This procedure is commonly performed when the normal biliary drainage into the duodenum is disrupted due to obstruction, injury, or resection. It is named after César Roux, who first described the Y-shaped anastomosis.

This operation is a crucial part of hepatobiliary surgery and is commonly used in cases of benign or malignant biliary obstruction, bile duct injury, choledochal cysts, and selected cases following liver transplantation or pancreatic surgeries. It plays a vital role in restoring bile flow into the small intestine, which is essential for digestion and absorption of fats and fat-soluble vitamins.

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Anatomy and Physiology of the Biliary Tract

The biliary system includes the liver, gallbladder, bile ducts, and associated structures that transport bile. The intrahepatic bile ducts merge to form the right and left hepatic ducts, which unite to form the common hepatic duct (CHD). The CHD is joined by the cystic duct from the gallbladder to form the common bile duct (CBD), which drains into the duodenum at the ampulla of Vater.

Bile is produced by the liver and stored in the gallbladder. Its release into the small intestine aids in the digestion of lipids. Any interruption in this flow can lead to cholestasis, jaundice, and serious metabolic disturbances.

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Indications for Roux-en-Y Choledochojejunostomy

Benign Conditions

Iatrogenic bile duct injuries (most commonly during laparoscopic cholecystectomy)

Choledochal cysts

Bile duct strictures due to chronic inflammation (e.g., primary sclerosing cholangitis)

Post-inflammatory or ischemic strictures

Congenital biliary atresia (especially in children)

Malignant Conditions

Cholangiocarcinoma

Gallbladder carcinoma

Pancreatic head tumors

Ampullary carcinoma

Hepatocellular carcinoma with bile duct invasion

Other Conditions

Liver transplantation (biliary reconstruction)

Failed endoscopic or percutaneous interventions for biliary drainage

Complicated gallstone disease with secondary biliary obstruction

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Preoperative Evaluation

A comprehensive evaluation is essential before planning a Roux-en-Y Choledochojejunostomy. This includes:

Clinical Evaluation

History of jaundice, abdominal pain, previous surgeries

Physical examination to assess signs of chronic liver disease or sepsis

Laboratory Tests

Liver function tests (LFTs)

Coagulation profile

Complete blood count (CBC)

Renal function tests

Imaging Studies

Ultrasonography to assess biliary dilation and stones

MRCP (Magnetic Resonance Cholangiopancreatography) for non-invasive bile duct imaging

ERCP (Endoscopic Retrograde Cholangiopancreatography) for diagnosis and therapeutic interventions

CT scan or MRI for staging in malignancy

Percutaneous Transhepatic Cholangiography (PTC) in selected cases

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Surgical Technique

General Principles

Performed under general anesthesia

Can be done via open or laparoscopic approach

Requires skilled hepatobiliary surgeon
Steps of the Procedure
1. Laparotomy or Laparoscopic Access
The abdomen is opened via midline incision or laparoscopic ports.
Adhesiolysis may be needed in previously operated abdomens.
2. Exposure and Dissection
The hepatoduodenal ligament is dissected to expose the CBD.
Care is taken to preserve vascular structures and prevent further injury.
3. Preparation of the Bile Duct
The CBD is transected, and the distal end is closed or resected.
The proximal duct is trimmed and prepared for anastomosis.
4. Preparation of the Roux Limb
A 40–60 cm segment of the jejunum is identified approximately 20–30 cm distal to the ligament of Treitz.
The jejunum is transected, and the distal limb (Roux limb) is brought up to the bile duct through a retrocolic or antecolic route.
5. Jejunojejunostomy
A side-to-side or end-to-side jejunojejunostomy is performed to restore bowel continuity between the proximal jejunum and the distal limb.
6. Choledochojejunostomy
An end-to-side or side-to-side anastomosis is created between the CBD and Roux limb.

Anastomosis can be single-layer or double-layer, using absorbable or non-absorbable sutures.
7. Drain Placement and Closure
Closed suction drains may be placed near the anastomosis.
Abdominal closure is performed in layers.
Variants and Technical Considerations
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