The art and craft of biliary T-tube Use

Since the universal adoption of Hans Kehr's biliary T-tube in the early twentieth century, use has shifted from routine towards highly selective. Improved interventional endoscopy, percutaneous techniques, and hepato-pancreato-biliary (HPB) training have resulted in less T-tube experience within general surgery. The aim of this technical review is to discuss T-tube indications, technical nuances, and management.Peer-reviewed literature, combined with high volume HPB experience by the authors, was utilized to construct a 10-step conceptual pathway for safe T-tube usage.Essential concepts surrounding T-tube use include: 1. Contemporary indications for T-tube insertion (disease-, patient-, and anatomy-based); 2. Correct instrument availability (open and laparoscopic); 3. T-tube selection and mechanical preparation; 4. Atraumatic T-tube insertion and security; 5. Immediate postoperative management and meticulous T-tube care; 6. Imaging biliary T-tubes; 7. Optimal timing of T-tube removal; 8. Technical aspects of T-tube removal; 9. Management of potential T-tube inpatient complications; and 10. Management of T-tube complications in the outpatient setting.Although their use has decreased substantially, the role of biliary T-tubes in some patients is essential. Given the reality of less frequent experience with T-tube insertion and management, this 10-step pathway will provide an adequate mental and technical framework for safe biliary T-tube use.Expert opinion, level V.