J Med Assoc Thai Vol. 93 Suppl. 2 2010 S39
Correspondence to: Akranurakkul P, Department of Surgery,
Srinakharinwirot University, Bangkok 10110, Thailand. Fax:
037-395-271. E-mail: email@example.com
Laparoscopic Biliary Bypass with an Autologous Tubed
Gastric Flap: A Pilot Study
Prinya Akranurakkul MD*,
Somkiat Wattanasirichaigoon MD*, Ekkit Surakarn MD*
*Department of Surgery, Faculty of Medicine, Srinakharinwirot University, Bangkok, Thailand
Although biliary bypass technique which used jejunum as a conduit is a common procedure in open
technique of hepatobiliary tract surgery, its complicated technique made it is not feasible for laparoscopic
surgery. Before 1960, stomach was used vastly for biliary drainage but late stricture which resulted from too
much tension along suture line made it not much acceptable. The authors report surgical technique of
laparoscopic gastric tube flap for biliary bypass in order to made it practicable for laparoscopic surgery.
Keywords: Laparoscopic surgery, Biliary bypass technique, Gastric tube flap, Biliary-gastric bypass, Animal
J Med Assoc Thai 2010; 93 (Suppl. 2): S39-42
Full text. e-Journal: http://www.mat.or.th/journal
Obstructive jaundice is one of the most com-
mon surgical problems which caused from both benign
and malignant conditions. Biliary drainage can be done
by many techniques including endoscopy(1-4), inter-
vention radiology(5)or surgical drainage(6). In addition
to relief symptoms of obstructive jaundice, the proce-
dure should resemble to normal physiology of biliary
system. Since 1940, many biliary bypass techniques
have been developed such as hepatico-gastrostomy,
hepaticoduodenostomy, hepaticojejunostomy (Roux-
en-Y or Braun’s loop); most of them have different ad-
vantages and disadvantages. Among them, jejunum
has been used widely as a conduit for biliary drainage
particularly in open surgery because it easily acces-
sible and movable to proximal bile duct anatomosis.
Laparoscopic surgery has developed rapidly
and gained much acceptable among surgeons. Some
techniques cholecystectomy have replaced traditional
operations such as laparoscopic. However, laparos-
copic biliary bypass using jejunum as a conduit is time-
consuming procedure and needs experienced
laparoscopic surgeon. Before 1960, hepaticogas-
trostomy was used as a biliary bypass procedure, but
anastomosis stricture which caused from too much ten-
sion along the suture line resulted in poor outcome.
The authors introduced a new technique by using au-
tologous tubed gastric flap (ATGF) as a conduit for
biliary bypass in order to decrease tension at the anasto-
motic site. Additionally, an ATGF can be done easier
than jejunal conduit under laparoscopic technique.
Material and Method
Three pigs which weigh 20-30 kilograms were
selected for the experiment. The operations were done
under general anesthesia using laparoscopic technique.
The authors resected part of stomach to create a tubular
structure (ATGF) which could be easily anastomosed
to the gallbladder as a part of biliary system.
Basic laparoscopic set, 0° and 30° 10-mm tele-
scope, Multi-fired Endo GIA 60 were used in this
A 10-mm trocar was inserted at supraumbilicus
for camera port, then two 5-mm trocars were inserted at
the right and left subcostal margin along anterior axillary
line. Lastly, two 10-mm trocars were placed at right and
left midclavicular line between the previous two ports.
The surgeon stood on the left side of the table and the
first assistance stood on the right (Fig. 1).