1. Date of download: 7/8/2016 Copyright © 2016 American Medical Association. All rights reserved. From: Operative Repair of Bile Duct Injuries Involving the Hepatic Duct Confluence Arch Surg. 1999;134(7):769-775. doi:10.1001/archsurg.134.7.769 A, Percutaneous transhepatic cholangiogram showing a surgical clip (arrow) occluding the common hepatic duct just below the confluence. B, Coronal single-shot fast spin-echo magnetic resonance cholangiopancreatography section showing a surgical clip (arrow) occluding the common hepatic duct just below the confluence. (Reprinted with permission from Radiology. Copyright 1998, Radiological Society of North America.) C, Coronal single-shot fast spin-echo magnetic resonance cholangiopancreatography section in a patient with recurrent cholangitis after multiple attempts to repair a postcholecystectomy bile duct injury. The hepatic duct confluence (white arrow) is shown. There is also excess fluid noted in the adjacent colon (black arrow), suggesting a fistula from the biliary tree to the hepatic flexure. Surgical findings confirmed a fistula from the right posterior sectoral hepatic duct that had been excluded from the anastomosis. (Reprinted with permission from Radiology. Copyright 1998, Radiological Society of North America.) Figure Legend:

2. Date of download: 7/8/2016 Copyright © 2016 American Medical Association. All rights reserved. From: Operative Repair of Bile Duct Injuries Involving the Hepatic Duct Confluence Arch Surg. 1999;134(7):769-775. doi:10.1001/archsurg.134.7.769 Cross-sectional T 1 -weighted magnetic resonance image showing an atrophic left hepatic lobe (black arrow) with dilated and crowded intrahepatic ducts (white arrow). Figure Legend:

3. Date of download: 7/8/2016 Copyright © 2016 American Medical Association. All rights reserved. From: Operative Repair of Bile Duct Injuries Involving the Hepatic Duct Confluence Arch Surg. 1999;134(7):769-775. doi:10.1001/archsurg.134.7.769 Right lobe atrophy and compensatory left lobe hypertrophy. A, The normal relationship of the porta hepatis structures is shown. B, With right lobe atrophy and left lobe hypertrophy, the porta hepatis structures are rotated posteriorly and to the right. The portal vein comes to lie more anteriorly with respect to the bile duct, which is rotated posterolaterally. (Reprinted with permission from Surg Clin North Am. Copyright 1994, WB Saunders Co.) Figure Legend:

4. Date of download: 7/8/2016 Copyright © 2016 American Medical Association. All rights reserved. From: Operative Repair of Bile Duct Injuries Involving the Hepatic Duct Confluence Arch Surg. 1999;134(7):769-775. doi:10.1001/archsurg.134.7.769 Roux-en-Y hepaticojejunostomy with an extended access loop. The blind end is anchored in the subcutaneous tissues of the abdominal wall. The anastomosis is splinted with a transjejunal tube. The tube track provides access for the interventional radiologist. Selected patients likely to require further manipulations may benefit from this approach. (Reprinted with permission from Surgery of the Liver and Biliary Tract. Copyright 1994, Churchill-Livingstone.) Figure Legend:

5. Date of download: 7/8/2016 Copyright © 2016 American Medical Association. All rights reserved. From: Operative Repair of Bile Duct Injuries Involving the Hepatic Duct Confluence Arch Surg. 1999;134(7):769-775. doi:10.1001/archsurg.134.7.769 A, Schematic sagittal section showing the relationship of segment IV (quadrate lobe [Q]) to the left hepatic duct (A). The caudate lobe (CL, segment I), left portal vein (B), and left hepatic artery (C) are also shown. The left portal triad is encased in a reflection of the lesser omentum, which fuses with the Glisson capsule at the base of the quadrate lobe. The point of incision to lower the hilar plate is indicated by the arrow. (Reprinted with permission from Surgery of the Liver and Biliary Tract. Copyright 1994, Churchill- Livingstone.) B, Exploded view of the liver showing its segmental anatomy. The left hepatic duct always pursues an extrahepatic course at the base of the quadrate lobe (segment IV), within the groove separating it from the caudate lobe (segment I; see Figure 7). The ligamentum teres marks the umbilical fissure. The extrahepatic portion of the right hepatic duct is more variable and shorter than the extrahepatic portion of the left hepatic duct. (Reprinted with permission from Surg Clin North Am. Copyright 1994, WB Saunders Co.) Figure Legend:

6. Date of download: 7/8/2016 Copyright © 2016 American Medical Association. All rights reserved. From: Operative Repair of Bile Duct Injuries Involving the Hepatic Duct Confluence Arch Surg. 1999;134(7):769-775. doi:10.1001/archsurg.134.7.769 Opening the umbilical fissure requires dividing the bridge of liver tissue that often connects segments III and IV, which may be substantial in some patients. This can be done easily by passing a curved director and dividing the tissue with electrocautery, taking care to avoid injuring the underlying left portal triad. Dissection is facilitated by firm upward traction on the ligamentum teres, which exposes the undersurface of the liver. (Reprinted with permission from Surgery of the Liver and Biliary Tract. Copyright 1994, Churchill-Livingstone.) Figure Legend:

7. Date of download: 7/8/2016 Copyright © 2016 American Medical Association. All rights reserved. From: Operative Repair of Bile Duct Injuries Involving the Hepatic Duct Confluence Arch Surg. 1999;134(7):769-775. doi:10.1001/archsurg.134.7.769 The hilar plate has been lowered and the left hepatic duct identified at the base of the quadrate lobe (segment IV). The right and left hepatic ducts may be further exposed with dissection toward the patient's right and the umbilical fissure, respectively. If necessary, the right portal pedicle can be further exposed by splitting the hepatic parenchyma in the plane of the gallbladder fossa (dashed line). A Roux-en-Y loop of jejunum has been prepared and brought through the transverse mesocolon. (Reprinted with permission from Surg Clin North Am. Copyright 1994, WB Saunders Co.) Figure Legend:

8. Date of download: 7/8/2016 Copyright © 2016 American Medical Association. All rights reserved. From: Operative Repair of Bile Duct Injuries Involving the Hepatic Duct Confluence Arch Surg. 1999;134(7):769-775. doi:10.1001/archsurg.134.7.769 A, The initial step in creating a Roux-en-Y hepaticojejunostomy. The anterior row of sutures on the bile duct is placed first. Working from left to right, the sutures are passed from inside out and secured on a clamp with the needles left in place. B, The anterior sutures are elevated to display the posterior duct wall. The posterior sutures are now placed, from jejunum to bile duct, again working from left to right. None of the sutures is tied but rather secured with a clamp until the entire row is completed. This allows unhindered access to the back wall of the bile duct and precise placement of each stitch. Inset, If multiple separate anastomoses must be performed, the entire anterior row of sutures is placed first to all exposed ducts followed by the posterior row. This allows the separated duct orifices to be treated as if single. (Reprinted with permission from Surg Clin North Am. Copyright 1994, WB Saunders Co.) Figure Legend:

9. Date of download: 7/8/2016 Copyright © 2016 American Medical Association. All rights reserved. From: Operative Repair of Bile Duct Injuries Involving the Hepatic Duct Confluence Arch Surg. 1999;134(7):769-775. doi:10.1001/archsurg.134.7.769 The anterior and posterior row of sutures are in place and held taut. The jejunum is slid upward along the posterior sutures until its back wall is flush with the back wall of the duct. The posterior sutures are tied and cut, leaving the corner sutures clamped. (Reprinted with permission from Surgery of the Liver and Biliary Tract. Copyright 1994, Churchill-Livingstone.) Figure Legend:

10. Date of download: 7/8/2016 Copyright © 2016 American Medical Association. All rights reserved. From: Operative Repair of Bile Duct Injuries Involving the Hepatic Duct Confluence Arch Surg. 1999;134(7):769-775. doi:10.1001/archsurg.134.7.769 With the posterior row secured, the anterior row is completed. Working from right to left, the needles of the previously placed anterior row are serially passed outside inward through the anterior jejunal wall. The sutures are not tied until all have been placed. (Reprinted with permission from Surgery of the Liver and Biliary Tract. Copyright 1994, Churchill-Livingstone.) Figure Legend:

11. Date of download: 7/8/2016 Copyright © 2016 American Medical Association. All rights reserved. From: Operative Repair of Bile Duct Injuries Involving the Hepatic Duct Confluence Arch Surg. 1999;134(7):769-775. doi:10.1001/archsurg.134.7.769 A, The anterior row of sutures has been placed and each is then tied, working from left to right. B, The completed anastomosis with all knots inside for better mucosal apposition. (Reprinted with permission from Surgery of the Liver and Biliary Tract. Copyright 1994, Churchill-Livingstone.) Figure Legend: