1. Check pre op LFT’s, CBC, plts, coags, T and S
2. What did the US show?
85% of biliary atresia have no GB seen. If CBD seen -> ? “Uncorrectable BA”.
3. What were the IDA and Biopsy results (if done). BA -> bile duct proliferation on biopsy
4. IV abts, NG, Foley, good IV access
5. Mark for chevron, but initially use only small incision over GB. “Bump” under the liver
6. Purse string top of GB if present with silk suture and do cholangiogram. “Uncorrectable BA” has good downstream flow into bowel but none up into liver. White bile means no proximal connection.
7. Take down the GB from distal to proximal; preserve the cystic artery if GB Kasai
8. Mobilize the liver. Divide the coronary ligaments and the falciform and put packing behind the liver to elevate it.
9. Identify the common hepatic artery and its branches to the left and right
10. Follow the arteries out to distal. Often there is a branch from the left hepatic to the GB bed, this can be divided.
11. Follow the falciform ligament down to the left portal vein.
12. The left portal vein is followed peripherally and several small branches toward the porta need to be suture ligated. A bridge of liver is divided with the cautery.
13. The right portal vein will have the right hepatic artery over it. This is followed out to?
14. The center of the portal triad is NOT where the microscopic ducts are. These are on the right and left as illustrated.
15. The porta is cored out with a hooked #12 blade running parallel to the vessels. The right and left extended dissection is critical.
16. A Roux-en-Y is mad by dividing the jejunum 10 cm distal to the ligament of Treitz, and is about 35 cm long.
17. In the rare case of a GB Kasai, the GB is spatulated and a 2.7 Broviac is used to drain it (exit the catheter via the suture line).