TECHNIQUE OF ‘KNOTS OUTSIDE’ BILIARY ANASTOMOSIS IN RIGHT LOBE LIVER TRANSPLANTATION

Background Biliary anastomosis is the achilles heal of living donor liver transplantation. Quite often Right lobe hepatic duct is less than 5mm in diameter. In such ducts if suture knots of posterior layer are intra luminal, then theoretically it can reduce intra luminal space for appropriate bile flow. At CLBS, we place the suture knots extra luminal for the posterior layer to prevent this complication. We herein describe our technique for the same Methods From July 2011 to August 2011, 41 patients underwent liver transplant, of these 38 were right lobe liver transplants. Biliary anastomosis were done using double ended ‘6 – 0’ PDS sutures. Initially the orientation of the CHD was assessed and the corner sutures were then placed transversely, inside out from the recipient CHD to the graft RHD. Then inside out sutures were placed at the anterior and posterior midpoint from the recipient to graft HD. This resulted in a diamond shaped area of anastomosis. Then first, the medial and later the lateral posterior half of the sutures were placed from the recipient to graft HD, all sutures being taken inside out. Following this railroading of the recipient duct over the sutures was done to approximate the 2 ducts and posterior sutures were knotted from midline to lateral and mid line to medial end of the anastomosis which allowed for the the knots to fall extraluminally. Anterior sutures were placed in standard fashion with all knots extraluminal. Results Of 38 Rt lobe transplants, 10 patients had ducts which were less than 5mm in size. All 10 patients had posterior layer knots placed extra luminally. None have developed bile leak or narrowing in the afore mentioned period. Conclusion Our technique of biliary anastomosis by placing the posterior layer suture knots extra luminally for ducts < 5mm in size, appears safe though it is technically demanding