End-to-side anastomosis of the common hepatic duct to the jejunum is another important step in pancreatic head duodenectomy. On the one hand, it is necessary to prevent bile duct-jejunum anastomotic leakage, and on the other hand, it is necessary to prevent postoperative bile-intestinal anastomotic stenosis. In order to improve the quality of bile duct and jejunum anastomosis, to ensure the long-term patency of the biliary-intestinal anastomosis, and to reduce the formation of anastomotic stenosis, scarless anastomosis should be advocated (a patent noncicatrical anastomosis). The concept, meaning, and technical skills of the scarless anastomosis are reflected in the following. Physicians specializing in pancreatic and biliary surgery should pay attention to this technique. (i) Bile duct-jejunum end-to-end anastomosis 1. How far from the pancreas-jejunum anastomosis should the bile duct be anastomosed to the jejunum? (1) Due to the different anatomical conditions of each patient, the number of extrahepatic bile ducts resected in each case of surgery is different, therefore, the distance of the broken end of the pancreas from the broken end of the bile ducts is not the same, so there is no fixed data from the pancreas-jejunum anastomosis how far the bile ducts are used to anastomose the bile ducts with the jejunum, and it should be selected according to the specific conditions of the different patients in the operation on an individualized basis. (2) Generally, the principle of comfortable jejunum placement without tension and folding is about 10 cm. (3) Application of Roux-y intestinal collaterals in surgery on-site than the test and marked with an electric knife, in order to reduce the tension between the two anastomoses, the biliary anastomosis position should be selected in addition to the other 1 to 2cm long is appropriate. 2.How to perform jejunostomy? (1) In the jejunum to the mesenteric edge of the scalpel marking at the stoma, with scissors in the jejunum to the mesenteric edge of the jejunum to cut a small mouth and 1/2 bile duct opening similar to the first cut the plasma muscle layer, and then in the center of the mucosa of the puffed up cut, or also cut a small piece of mucosa, so that the mucosal incision is smaller than the intestinal plasma muscle layer incision. (2) The jejunostomy procedure should be performed as far as possible without the use of an electrosurgical knife or electrocoagulation, as thermal burns from the knife tend to cause postoperative anastomotic scar formation. Can also choose to use a perforator in the jejunum proposed anastomosis to make a hole with the bile duct anastomosis, the perforator cut both the longitudinal muscle and cut off the circular muscle, and resected a small piece of mucosa. 3.How to deal with the broken end of the bile duct? (1) In order to ensure the blood supply of the severed end of the bile duct, the severed end of the bile duct should not be free for more than 0.5cm; (2) Use sharp scissors to cut off the bile duct, and do not use an electric knife to cut off the bile duct. This is because electrical burns on the severed end of the bile duct can lead to postoperative anastomotic stenosis. If the bile duct has been cut with an electric knife, the proximal end of the bile duct should be cut with scissors to remove a small section. (3) A biopsy of the severed end of the bile duct should be routinely taken for rapid frozen pathology to determine the absence of tumor residue. If the severed end is found to have tumor residue, it should be cut upward again to the place without tumor residue. 4.How to perform bile duct jejunum anastomosis? (1) If the bile duct is dilated (≥1.5cm), 4-0 or 5-0 absorbable thread can be used to apply a full-layer interrupted suture on the end side of the common hepatic duct – jejunum. The distance between needles is about 3-4mm, and the distance between margins is 2-3mm. the plasma muscle layer is more sutured, the mucosa is less sutured, and the wall of the bile ducts is sutured in its entirety, and the thread is ligated outside of the anastomosis. The knot should not be too tight, so that the anastomosis can be matched without leakage. The order of anastomosis is different for each operator, and should not be forced. (2) Suture selection: ① Round needle 4-0 or 5-0 absorbable thread, 4-0 Polydioxanone (PDS II RB-1), 4-0 silk thread, and so on. The principles should include no or minimal damage and minimal tissue reaction to the suture. The three sutures mentioned above are available. Absorbable sutures can be absorbed, however, the long absorption process of tissue reaction may increase the chance of incisional scar formation stenosis, which is not the best. (ii) Non-absorbable sutures are best used for anastomosis with fine silk sutures (No. 4-0). Tissue reaction to anastomosis with fine silk thread is mild and anastomotic scar formation is very mild. (iii) Anastomosis with 4-0 Polydioxanone (PDS II RB-1) is preferable because it combines the advantages of non-invasive and slow resorption. (4) 5-0 prolene non-invasive suture can also be used, especially in cases where the bile duct breaks against the portal vein or hepatic artery. (3) Anastomosis method: interrupted suture is mostly used; absorbable thread can also be used for continuous suture, which requires continuous tensioning of the anastomosis line, otherwise the suture line will be easy to relax and leak. (4) The practice of this group: interrupted suture is applied, and the thread is ligated outside the anastomosis. The interrupted suture is reliable. It is also very important to tie the thread outside the anastomosis. Especially non-absorbable thread must be ligated outside the anastomosis, because the anastomosis of the knot in the postoperative period can produce foreign body inflammatory granuloma on the knot, blocking the anastomosis; or secondary gallstones. If absorbable suture is used, interrupted suture is better than continuous suture, because continuous suture is not tight, anastomotic leakage is likely to occur, and once the anastomotic suture is disconnected, the entire anastomosis may be cracked. Continuous anastomosis should be performed with continuous tightening of the suture. The chance of anastomotic leakage is increased with inaccurate continuous suturing. (5) Mucosa-to-mucosa healing can only be achieved by suturing the jejunal plasma muscle layer to the entire bile duct. Because, ① during the implementation of bile-intestinal anastomosis, mucosal ectropion is incorrect, affecting the healing; ② mucosal inversion is desirable to make the anastomosis narrow; ③ due to the thick wall of the intestinal canal and the thin wall of the bile ducts, it is difficult to achieve the mucous membrane to mucous membrane. Only the jejunal plasma muscle layer and bile duct whole layer suture to achieve plasma muscle layer to plasma muscle layer anastomosis, is appropriate. (6) Anastomotic order: each person’s habits are different, the only standard is to ensure that the anastomosis is not twisted. The author used to sew the posterior wall midpoint (6 points) as the first stitch, or then the anterior wall midpoint (12 points) suture and pull to make the biliary anastomosis become a longitudinal mouth, so that the anastomosis is positioned and operated properly. ② And then to both sides of the suture, from 6 points to 3 points; and then from 6 points to 9 points, sewing a needle ligation a needle, to ensure that the plasma muscle layer to the plasma muscle layer, to complete the posterior wall anastomosis; ③ And then from 3 points to 9 points, to complete the anterior wall of the suture. The plasma membrane of the hepatoduodenal ligament (the so-called hepatic portal plate) should be sutured together during the anterior wall anastomosis. It should be ensured that the anastomosis is not twisted. (7) Once the bile duct dissection is close to a blood vessel (portal vein and/or hepatic artery), it is best to close the wall of the bile duct and then the jejunum accurately with a 5-0 prolene suture, rather than sewing to the vessel wall. Because, the consequence of sewing on the vessel wall will be postoperative perioperative hemorrhage in the form of abdominal hemorrhage or bile duct hemorrhage. In the surgery of hilar cholangiocarcinoma, there is a Glisson’s sheath between the posterior wall of the hilar bile duct and the bifurcation of the portal vein, which is favorable for anastomosis. 5. Is it necessary to place an endobiliary support tube? (1) In most patients with obvious bile duct dilatation (≥15mm) and confident pancreatico-intestinal anastomosis, a bile duct support tube may not be necessary. Role of the bile duct support tube On the one hand, it is used to support the internal drainage of the bile duct, and on the other hand, it can decompress the intestinal lumen in the anastomotic region, which plays a more important role in the prevention of anastomotic leakage. (2) there are many kinds of internal support tube, there are mainly three kinds, (1) a kind of internal support tube at the same time line external drainage, often choose a variety of caliber T-tube, cut off the end of the T-tube cross arm before use; or use a straight silicone tube as a drainage tube. ② another simple internal support tube for internal drainage, choose a variety of high-quality elasticity good lumen silicone catheter, the length of 3 to 5 cm, mainly placed in the anastomosis to support the anastomosis. (iii) T-tube drainage of the common hepatic duct, in the bile-intestinal anastomosis above the 2cm cut small mouth placed corresponding caliber of the T-tube, T-tube cross arm cutting, the upper end into the intrahepatic bile duct, the lower section of the bile-intestinal anastomosis into the jejunum. This method both supports the drainage of the bile duct and has a decompression effect on the jejunal collaterals. (3) The bile duct support tube should not be inserted too deep into the bile duct: if it is inserted deeply, it will block the bile duct branches and affect the bile discharge; in fact, the main role of the bile duct support tube is to support the anastomosis for a short period of time; it is appropriate to see bile overflow from the support tube after inserting the support tube in the operation, and it is generally ≤3cm. (4) Fixation of the support tube (1) The support tube is fixed by sewing directly with a direct suture. The support tube should be fixed by sewing with the bile duct of the anastomosis and the wall of the intestinal tube with absorbable suture to prevent early slippage and displacement of the support tube. The support tube should be fixed with absorbable suture to the bile duct and intestinal wall of the anastomosis to prevent the support tube from slipping and shifting at an early stage. Close the bowel wall and the support tube with absorbable suture, pull the suture to the intended position and then close the bile duct wall with separate suture and ligation. Do not suture the intestinal wall, the supporting tube, and the bile duct at the same time and then pull the suture, because such pulling of the suture may cause pinhole tears in the bile duct wall and postoperative bile leakage. ② Tie the support tube with No. 1 silk thread at the predetermined position, then use anastomotic suture to close the intestinal and bile duct walls, and at the same time bring 3 to 4 stitches of the ligature thread on the support tube. This method is preferred. (5) Internal and external drainage of the bile duct support tube is superior: it can reduce the local intestinal lumen pressure and prevent anastomotic leakage. An internal support tube alone cannot be managed once the catheter is occluded. However, once there are multiple bile duct openings (e.g. hepatoportal cholangiocarcinoma), it is impossible to put multiple bile ducts for external drainage, at this time, it is feasible and applicable to put a short supporting tube for internal drainage in the small bile duct opening. 6.How to perform bile duct jejunostomy when the common hepatic duct is not dilated? (1) Built-in support tube bile duct jejunum anastomosis, i.e., bile duct jejunum mucosal papilloplasty ①Indications: A few pancreatic leptomeningeal tumors, jaundice has not yet appeared at the time of admission to the hospital for surgery, and the extrahepatic bile ducts do not dilate (≤1.5cm), and the caliber of the bile ducts is close to normal (<10mm), which makes bile duct and jejunum anastomosis somewhat difficult. Postoperative anastomotic stenosis is also more likely to occur. ②Surgical techniques: a choose the appropriate caliber catheter, generally 12-16 T-tube, insert one end of the catheter into the common hepatic duct for 3 cm, and fix the catheter with 3 interrupted sutures on the edge of the bile duct with 5-0 absorbable thread to prevent the catheter from falling off. The fixation method was the same as above. b In the proposed anastomosis at the jejunal wall cut small holes, with the catheter caliber size, cut off the plasma muscle layer to retain the mucosal layer; in the center of the mucosa poke holes, the introduction of the catheter and in the far 15cm from the jejunal wall lead, pulling the catheter so that the broken end of the bile ducts into the jejunum and by the jejunum mucosal cover, then the 4-0 silk thread will be the jejunostomy at the plasma muscle layer with the bile duct peripheral tissues and the peritoneum intermittent suture. With this anastomosis, the jejunal mucosa covers the surface of the bile duct severed end and heals with the bile duct, and the jejunal plasma muscular layer heals with the periportal tissues to ensure the patency of the bile duct. It constitutes bile duct jejunal mucosa papilloplasty. (3) Surgical evaluation: a For non-dilated cases of the bile duct, in order to ensure the reconstruction of the bile-intestinal anastomosis and prevent postoperative anastomotic stenosis, a supportive drain of the corresponding caliber should be placed in the bile duct and supported for >3 months postoperatively. b Focusing on the supportive anastomosis, the insertion of the supportive tube into the bile duct should therefore not be too deep, so as not to interfere with the drainage of bile from the associated hepatic bile ducts. c Proposed by the group and clinically applied for many years has received better results, and it is worth promoting. (2) Gallbladder jejunoileal anastomosis (described separately below) (2) Gallbladder jejunoileal anastomosis 1, indications: (1) the caliber of the bile ducts to be anastomosed is small (10mm); (2) the bile ducts are patent; (3) the point of confluence of the bile ducts and the common hepatic duct is higher than the level of the bile ducts above the level of the transverse section of the bile ducts above 1cm; (4) there is no pathology in the gallbladder itself, including severe acute and chronic inflammation or tumors. Surgical techniques: (1) Firstly, confirm that there is no opening of the cystic duct at the bile duct severed end of the proposed anastomosis; (2) Squeeze the gallbladder to see the concentrated bile overflowing from the bile duct; (3) Peep through the bile duct opening to see the opening of the cystic duct above the bile duct severed end; (4) Successively suture the bile duct severed end of the bile duct with 6-0 prolene to make sure that there is no leakage, or use Hem-o-lock to clamp the bile duct severed end; (5) Confirm that the gallbladder is full and tense prior to proposed cholecysto-jejunoileostomy; (6) Set up the anastomosis in a position where there is no leakage. increased; (6) The anastomosis was located at the lower edge of the gallbladder floor; (7) The anastomosis was 3 cm long and cut into an oval shape with scissors to ensure adequate patency; (8) The jejunal collaterals were ensured to be free of tension; the jejunal anastomosis was similarly cut into an oval shape; and (9) The entire mucosa was sutured intermittently mucosa-to-mucosa using a 4-0 absorbable thread with the thread ligated outside the anastomosis. 3, the evaluation of the operation: (1) the bile duct is a bidirectional channel to ensure the smooth drainage of bile into the gallbladder; (2) due to the special anatomical structure of the bile duct and the cystic duct and the pressure in the bile duct can prevent intestinal fluid and bile reflux; (3) gallbladder jejunum anastomosis caliber is large postoperative anastomotic stenosis will not occur; (4) the anastomosis is easier; (5) the intraoperative bile duct margins of the premise of the frozen pathology of the negative does not affect the tumor resection of the thoroughness of the tumor; (6) the postoperative bile drainage smoothness rate is high in the long-term. drainage patency is high. Therefore, cholecysto-jejunal anastomosis is considered to be a worthwhile procedure in selected cases.