Introduction 1 Materials and Methods Case Report 1 2 Figure 1 (a) (b)  Figure 2 Preoperative fistulogram in which contrast was injected through the existing U-tube. The cutaneous opening at the upper left side of the frame is in continuity with the large contrast-filled channel that enters the substance of the liver. Note the complete absence of an extrahepatic biliary system.  Surgical Procedure 3 Figure 3 (a) (b)  4 Figure 4 (a) (b)  The abdominal cavity was irrigated and closed in the standard fashion. The patient tolerated the 3-h procedure well. Blood loss was minimal. He was discharged on postoperative day 8. Result This patient has now been followed for 7 years since the described procedure and is doing well without external drainage of bile. The condition of his periincisional skin improved dramatically shortly after the procedure. At this time his liver function tests and nutritional parameters are normal and his graft function remains adequate on a low dose immunosuppressive regimen. Discussion 2 3 1 4 5 5 1 4 4 6 9 11 10 4 12 12 Deepithelialization of the skin opening and its direct usage in an anastomosis has not, to our knowledge, been previously described. Furthermore, this procedure is unique in that the internalization was done in the case of a functioning liver after hepatic artery thrombosis. The existing anatomy that had been established over 7 years of fistulous drainage dictated the type of procedure that was performed. In contrast to fistulas that arise after biliary tract surgery (for example, after cholecystectomy with common bile duct exploration), there was no remnant of a previous biliary ductal system. The preoperative fistulogram revealed flow of contrast from the skin directly to the liver surface with no evidence of an extrahepatic ductal system. The fistula therefore provided the only source of biliary drainage for the entire liver. An alternative surgical option would have been hepaticojejunostomy, in which the jejunum would have been sutured to a fibrous ring at the origin of the fistula tract from the liver surface. This, however, would have required more extensive dissection with possible disruption of collateral vasculature to the previously ischemic liver and to the tract itself, as well as dissection of the transverse colon, which in part bordered the tract. At operation, the superficial portion of the fistula tract was well established and appeared well vascularized. The potentially harmful deep dissection necessary for a hepaticojejunostomy was therefore avoided. We emphasize the decision to have fashioned a tongue of omentum over the anastomosis. By nature, the tissue comprising a fistula tract is probably somewhat tenuous. This patient’s immunosuppressed and malnourished state compound the risk of anastomotic breakdown. We feel that the well-vascularized, adherent omental tongue was an important aspect of the operation in reinforcing the anastomosis. As of 7 years of follow-up, the patient has not developed signs of biliary obstruction. His immunosuppressant levels are easier to maintain and he does not have evidence of malabsorption. It is unlikely that he will develop cicatricial narrowing of the tract, as it had remained well epithelialized for the 7 years before this operation. There is a theoretical concern about formation of squamous cell carcinoma at the anastomotic site, which we continue to keep in mind during long-term follow-up. Conclusion In summary, through a novel approach this patient’s biliary cutaneous fistula was internalized, which has eliminated his associated skin morbidity and malabsorption. Furthermore, his well-functioning graft was salvaged, thus saving the cost of retransplantation and sparing an additional liver for another patient. Internalization of a long-standing biliary cutaneous fistula through deepithelializing the skin opening and using the tract as a conduit is technically feasible. We believe it to be a valid approach in the patient in whom there is no existing biliary ductal system or the existing system anatomically does not lend itself to restoration of functional internal biliary drainage by conventional approaches.