Biliary tract surgery in the dog and cat:

Indications and techniques

Ivan Doran BVSc Cert SAS MRCVS
Alasdair Hotston Moore MA VetMB Cert SAC Cert VR Cert SAS MRCVS
DEPARTMENT OF CLINICAL VETERINARY SCIENCE, UNIVERSITY OF BRISTOL, LANGFORD HOUSE,
LANGFORD, BRISTOL. BS40 5DU

ANATOMY (Fig. 1) l Extramural causes of biliary obstruction include

neoplasia (duodenal, pancreatic) and pancreatitis
(Fig. 3).
l Biliary peritonitis (Fig. 4) occurs when bile leaks
from the extrahepatic biliary system.This can occur

Gall bladder

Hepatic ducts

Cystic duct

Hepatic ducts

Common bile duct

Fig. 2: Biliary obstruction secondary to biliary

Duodenum
carcinoma of the common bile duct in a cat.

Intramural
bile duct

Major duodenal
papilla
Minor pancreatic
papilla

Pancreas

Fig. 1: Normal canine biliary anatomy (redrawn from Miller’s

guide to the dissection of the dog; third Ed).
Fig. 3: Cat with obstructive jaundice secondary to

CLINICAL PRESENTATIONS
pancreatitis.

The extrahepatic biliary tract of dogs and cats can be

affected by a variety of diseases, either due to
primary pathology of the biliary system or as a result
of disease in another organ causing secondary
dysfunction of the biliary tree. Although a wide
range of causes of extrahepatic biliary dysfunction
exist, these all result in either obstruction to bile flow
or to leakage of bile into the peritoneal cavity.
l Intraluminal causes of biliary obstruction include
inspissation of biliary secretion, cholelithiasis and
mucinous debris resulting from gallbladder
mucocoeles.
l Intramural causes of biliary obstruction include Fig. 4: Biliary peritonitis in a dog secondary to blunt
biliary neoplasia (Fig. 2) and cholangitis. abdominal trauma.

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 secondary to necrotising cholecystitis (Fig. 5),
trauma, usually affecting the biliary ducts or,
rarely, secondary to biliary obstruction.
Fig. 5: Biliary peritonitis and adhesions following gallbladder
rupture secondary to necrotising cholecystitis.
The commonest causes of biliary tract obstruction in
the dog are pancreatitis and neoplasia whilst in the
cat, a combination of inflammatory conditions such
as cholangitis, cholangiohepatitis, pancreatitis and
inflammatory bowel disease frequently co-exist. Cats
also regularly present with biliary obstruction
secondary to neoplasia.
Note: the authors have seen several cases of biliary
peritonitis that resulted from bile leaking through a
proximal duodenal perforation, into the peritoneal
cavity. These perforations were usually a result of
NSAID toxicity and the biliary tract itself was
normal.
DIAGNOSIS
A full discussion of the diagnosis of biliary
obstruction in dogs and cats is beyond the scope of
this article. Ultrasonography provides the best, readily
available, modality to image the biliary tract. Dilation
of the gallbladder and biliary ducts, along with an
increased tortuosity of the biliary tract (Fig. 6) is
suggestive of biliary obstruction, although it can be
difficult in some cases to distinguish between current
and recent but resolved biliary obstruction. Cases of
Fig. 6: Biliary tract dilation and increased tortuosity in
a cat following fibrosis of the common bile duct.
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biliary peritonitis may be suspected following
accumulation of fluid within the peritoneal cavity
and recovery of bile-containing fluid on
abdominocentesis (Fig. 4).
PREOPERATIVE CONSIDERATIONS
Haemorrhagic diathesis in dogs and cats with liver
disease is seldom a clinical problem, in contrast to the
situation in humans.Vitamin K deficiency can occur
secondarily to chronic biliary obstruction and this
can lead to lowered levels of clotting factors II,VII,
IX and X. Clinical cases of biliary obstruction in
dogs and cats are usually encountered before this
situation develops, but should these deficiencies be
suspected, subcutaneous administration of vitamin
K1 (at 1-2 mg/kg) is usually sufficient to normalise
coagulation within 3 to 12 hours of administration.
There is also strong evidence that chronic
obstructive jaundice, in dogs and in humans,
predisposes the patient to post-operative
hypotension and subsequent acute renal failure.
CHOLECYSTOTOMY
Primary indications for cholecystotomy include
removal of inspissated biliary ‘sludge’ or choleliths
from the gallbladder.
Cholecystotomy is only indicated when the
gallbladder wall remains healthy. It is imperative that
patency of the cystic duct and common bile duct is
confirmed before the gallbladder is closed. Biliary
tree cannulation is most readily achieved in a
retrograde fashion, via a duodenal incision (Fig. 7).
Anterograde cannulation, via the cholecystotomy
incision, is more difficult owing to the acute angle
between the cystic and the common bile ducts.
Fig. 7: Retrograde cannulation of the canine common
bile duct via a duodenal incision.
1. Laparotomy swabs are used to pack off the
gallbladder to minimise the risk of abdominal
contamination from gallbladder contents.
2. A stay suture is placed, into the fundus of the
gallbladder to facilitate atraumatic manipulation
during the procedure. Fine synthetic monofilament
suture material is used.
3. It may be possible to aspirate some of the
gallbladder contents, using a 16G needle. This
decompression will reduce the risk of spillage of
luminal contents during incision of the
gallbladder.
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4. Whilst an assistant applies traction to the stay
sutures, a generous incision is made from the
fundus towards the neck of the gall bladder.
5. Luminal contents are removed using tissue
forceps and/or lavage and suction.
6. The patency of the common bile duct and cystic
ducts is checked. An assistant’s fingers are
employed to occlude the duodenum either side
of the proposed duodenal incision site. An
antimesenteric duodenal incision is made
(centred approximately 4 cm distal to the pylorus
in a medium sized dog). Duodenal contents are
suctioned and the major duodenal papilla is
identified. A 4 Fr catheter is passed and the
biliary system flushed. The duodenal incision is
closed using a full thickness simple continuous
suture pattern with a synthetic absorbable suture
material.
7. The cholecystotomy incision is closed using a
monofilament absorbable suture material. The
suture line is begun at the gallbladder neck and
the initial knot’s short end is retained as a stay
suture. A biopsy of the gallbladder wall may be
taken first, but the authors recommend avoiding
cholecystotomy where mural disease is
suspected. Bacteriological culture and sensitivity
testing are performed on the bile.
CHOLECYSTECTOMY
Cholecystectomy is indicated when the gallbladder
is traumatised or diseased, and also when the
gallbladder is suspected to be the source of recurrent
biliary disease (e.g. gallbladder mucocoeles).
Cholelithiasis and cholecystitis (including the
necrotizing form, which may present with
perforation) can often be successfully treated by
performing a cholecystectomy. If a biliary tract
obstruction is suspected then the patency of the
common bile duct must be verified, as previously
described.
1. The region around the gallbladder is packed off
as for cholecystotomy.
2. A stay suture is placed into a non-friable area of
the apex of the gallbladder to facilitate
manipulation of the organ during dissection.
Choice of stay suture material is of little
consequence.
3. Cholecystocentesis is not necessary and it is
easier to follow an appropriate plane of dissection
around a turgid gallbladder.
4. Traction is applied using the stay suture and a
pair of Metzenbaum scissors are used to incise
the visceral peritoneum between the gallbladder
and its hepatic fossa. This visceral peritoneal
incision is progressively extended around the
entire liver-gallbladder junction in order that a
clean plane of dissection can be subsequently
maintained. Blunt dissection between the
gallbladder and the hepatic fossa is continued,
using Metzenbaum scissors, a rounded suction
tip or by finger dissection. Minor haemorrhage
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from the liver surface is controlled by gentle
pressure with a swab.
5. Mobilisation of the gallbladder and proximal
cystic duct is effected and then the cystic duct is
cross clamped. A distal cystic duct ‘stump’ is left
so that the hepatic ducts from the central
division of the liver are not ‘pinched’ by the
clamp, at their junction with the cystic duct.The
gallbladder and proximal cystic duct are
removed. If an obstructive biliary disease is
suspected, then before the cystic duct is clamped,
an incision is made into the gallbladder to permit
retrograde flushing of the biliary tract, via the
duodenum (see cholecystotomy), to ensure the
patency of the common bile duct. The cystic
duct and cystic artery are then ligated with a
single ligature using synthetic absorbable suture
material, before being sectioned proximal to the
ligature.The gallbladder should be submitted for
histological and microbiological analysis (Fig. 8).
Fig. 8: Excised gall bladder from a cat.
CHOLECYSTODUODENOSTOMY
Cholecystoduodenostomy is indicated to bypass sites
of obstruction or trauma affecting the extrahepatic
biliary tree. It is widely considered to be the most
useful procedure for biliary diversion in dogs and
cats. It is used when the gallbladder is not directly
involved in the disease process. It is also used for
management of extrahepatic biliary tract rupture,
together with ligation of the common bile duct.
1. The gallbladder is packed off using laparotomy
swabs.
2. A stay suture is placed in the gallbladder, as
previously described for cholecystotomy. Stay
sutures are also placed in the antimesenteric
border of the proximal duodenum, approximately
5 cm apart.
3. The gallbladder is mobilised away from the
hepatic fossa, as for cholecystectomy. Care is
taken not to traumatise the gallbladder wall or
the cystic artery as it courses with the cystic duct
to invest the gallbladder wall. Complete
mobilisation of the gallbladder up to its junction
with the cystic duct is crucial to permit a
tension-free anastamosis to the duodenum, and
so minimise the risks of biliary leakage, wound
dehiscence and stoma stricture post-operatively.
NB It is easier to achieve a tension free
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 anastomosis between the gallbladder and the
jejunum but this is a less physiological technique
and predisposes the patient to duodenal
ulceration.
The presence of bile in the duodenum is, in fact,
integral to the neuroendocrine mechanisms
responsible for inhibiting gastric acid secretion. It
is not necessary to dissect free the cystic duct
itself to achieve an adequately mobilised
gallbladder, and such a dissection exposes the
cystic artery to the risk of iatrogenic trauma as it
accompanies the cystic duct in its course.
4. An assistant applies traction to both the
gallbladder and duodenal stay sutures, in order to
appose the gallbladder’s longitudinal axis and the
antimesenteric aspect of the proximal
duodenum. Care is taken not to twist the cystic
duct during this manoeuvre.
5. A simple continuous, full thickness suture (Fig. 9)
is placed to appose the duodenum and
gallbladder. Synthetic absorbable suture material
is used. The end of the short limb of the initial
knot can be clamped and employed as a further
stay suture whilst the suture line is being
constructed.
Fig. 9: Cholecystoduodenostomy in a dog. The first suture
line has been completed.
6. A full thickness incision is made, along the
longitudinal axis of the gallbladder, adjacent and
parallel to the simple continuous suture line.This
incision should be as long as possible to limit the
risk of post-operative stoma stricture. A full
thickness incision, of the same length as the
gallbladder incision, is made at the
antimesenteric border of the proximal
duodenum, adjacent and parallel to the duodenal
incision. Biliary and duodenal contents are
aspirated from the vicinity of the incisions. A
second, full thickness, simple continuous suture is
placed to appose the near edges of the
gallbladder and duodenal incisions. If the ends of
the first suture line are tied but not cut, they can
then be tied to the respective ends of the second
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suture line, ensuring a complete seal around the
stoma (Fig. 10).
Laparoscopic stapling devices (e.g. the EndoGIA,
Tyco) can also be employed to create a swift,
effective and secure cholecystoduodenostomy.
Fig. 10: Completed cholecystoduodenostomy.
TREATMENT
There is a plethora of surgical techniques described
for treatment of biliary tract disease and trauma. In
veterinary medicine, the vast majority of situations
can be addressed by performing cholecystotomy,
cholecystectomy, or by effecting biliary diversion via
cholecystoduodenostomy. Cases of biliary
obstruction secondary to transient, non-biliary
disease (e.g. pancreatitis) may benefit from biliary
tract decompression via cholecystocentesis under
ultrasonographic guidance, whilst the primary
condition resolves. However, there is a significant
risk of leakage from the needle hole if the cause of
obstruction persists.Techniques of primary repair of
the biliary tract are less applicable to dogs and cats
than to humans. The comparatively narrow
extrahepatic biliary tract of our patients renders the
risks both of post-operative biliary leakage from the
repair site and of stenosis/stricture of the repair site,
much higher. Furthermore, clinical signs following
biliary tract rupture often have an insidious onset.
The time interval elapsing between rupture and
surgical intervention may therefore be sufficient to
permit adhesion formation between the biliary tract
and adjacent tissues, thus rendering primary repair
more difficult (Fig. 5). Stenting techniques are also
popular in human medicine but are often
inappropriate in dogs and cats because of the higher
risks of stent occlusion and because of difficulties
with regard to patient compliance.
COMPLICATIONS/PROGNOSIS
The prognosis for a patient following biliary tract
surgery is very much influenced by the underlying
pathology that is present. Cases of biliary tract
obstruction or rupture secondary to a neoplastic
process, usually pancreatic or biliary adeno-
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carcinoma, merit an extremely guarded prognosis.
The prognosis for patients with biliary peritonitis is
very much dependent on the presence of bacteria
within the peritoneal effusion. Animals with a septic
biliary peritonitis carry a considerably worse
prognosis than animals with a sterile biliary
peritonitis. Cats are generally recognized as
representing a greater challenge than dogs, in
achieving a successful outcome following biliary
surgery. The creation of a large stoma when
performing cholecystoduodenostomy will decrease
both the risks of post-operative stoma stenosis and of
reflux cholangiohepatitis.Atraumatic tissue handling,
careful attention to surgical technique, correct choice
of instrumentation and suture material and finally,
the selection of an appropriate procedure performed
on viable tissue are all major factors in the success of
surgery in addressing biliary tract problems.

FURTHER READING
FAHIE et al (1995) JAAHA 31[6]:478-482 Extrahepatic biliary tract
obstruction : a retrospective study of 45 cases (1983-1993).
MEHLER et al (2004) Vet Surg 33 [6]:644-649 Variables associated with
outcome in dogs undergoing extrahepatic biliary surgery : 60 cases
(1988-2002).
MAYHEW et al (2002) JSAP 43[6]:247-253 Pathogenesis and outcome of
extrahepatic biliary obstruction in cats.
PIKE et al (2004) JAVMA 224[10]:1615-1622 Gallbladder mucocoele in
dogs: 30 cases (2000-2002).
HERMAN et al (2005) JAVMA 227[11]:1782-1786 Therapeutic
percutaneous ultrasound-guided cholecystocentesis in three dogs with
extrahepatic biliary obstruction and pancreatitis.
LUDWIG et al (1997) Vet Surg 26[2]:90-98 Surgical treatment of bile
peritonitis in 24 dogs and 2 cats : a retrospective study (1987-1994)
BACON N. J. and WHITE R. A. (2003) JSAP 44[5]:231-235 Extrahepatic
biliary tract surgery in the cat: a case series and review.

© Photographs courtesy of Professor P. E. Holt, Alasdair Hotston

Moore and Ivan Doran.

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