Surgical technique
Adhesiolysis
ADHESIONS
Under general anesthesia, a right subcostal incision was performed and could be extended on demand upward to the xiphoid process and/or to the left subcostal area. Adhesiolysis of preformed adhesions if present and cholecystectomy were performed unless the gallbladder had already been removed. Cautious and thorough dissection was performed to reach the common bile duct (CBD) and common hepatic duct (CHD) and prepare a healthy proximal CHD for bilio-enteric anastomosis. Ductoplasy was performed when needed to provide single and wide anastomosis. For RYHJ-GA, a Roux jejunal loop of 70 cm length was prepared and passed retro colic to reach the porta hepatis. Then, the hepaticojejunostomy (HJ) was done via end-to-side anastomosis using interrupted sutures of polyglactin 4–0 size. The anastomosis was done 10–15 cm away from the free end of the Roux jejunum loop to allow anastomosis without tension to the stomach. The end of the Roux jejunal loop taken up for hepaticojejunostomy was not closed but was anastomosed to the anterior wall of the gastric antrum about 5cm proximal to the pyloric orifice (Fig. Hepaticojejunostomy with gastric access loop. 