In percutaneous transhepatic biliary drainage (PTBD), which access route is preferred to minimise risk of haemobilia and allow biliary drainage without traversing major vascular structures?

• A Left subcostal approach targeting segment 3 duct (left lobe) ✓
• B Right mid-axillary line access targeting right posterior sector ducts
• C Epigastric midline approach to the common hepatic duct
• D Right anterior approach targeting right anterior sector ducts

Explanation

Left lobe (segment 3) duct access via a subcostal/subxiphoid approach is increasingly preferred for PTBD because: the segment 3 duct has a predictable anterior location accessible under US guidance; it avoids traversal of the pleural space (unlike right intercostal approach which risks hydrothorax/pneumothorax); it allows a gentle, less angulated approach for biliary stent placement; and it avoids the major right-lobe vascular structures. Right mid-axillary access may require intercostal puncture risking pleural complications. The left approach is particularly favored for Klatskin tumors requiring bilateral drainage. All PTBD approaches carry risks of haemobilia, bile leak, and sepsis.

Reference: Grainger & Allison's Diagnostic Radiology, 7th ed.

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Written and medically reviewed by the StethoPrep medical team.