Exposure of the left hepatic duct through the hilum or in the umbilical of the liver: anatomic limitations

Anastomosis to the left hepatic duct approached by dissecting the hilar plate is the most reliable method of drainage of the left side of the liver in that longitudinal incision of the left hepatic duct allows a long cholangiojejunostomy. However, the anatomy is not satisfactory in 30% of cases for adequate drainage of the left side of the liver. To further clarify this surgically important area, 107 vasculobiliary casts were reviewed with regard to the anatomy and relationship between the left biliary ductal and left portal venous systems. In cases in which anatomy is unfavorable for adequate drainage by anastomosis to the left hepatic duct in the hilum, several options are available. The anterior portion of the main portal fissure may be opened to gain wide access to the superior aspect of the biliary plate and reach a posterior duct that is more suitable for anastomosis. An anastomosis to an anterior duct may also be possible with this approach. If left portal ducts are inaccessible by division of the main portal fissure because of a retroportal location, then an anastomosis in the anterior portion of the umbilical fissure may give adequate drainage. Therefore a cholangiogram is imperative before any anastomosis in the hilum or the anterior portion of the umbilical fissure.