Longmire surgery

Longmire surgery is used for the treatment of hepatic bile duct stricture. Longmire surgery, the left intrahepatic bile duct jejunostomy. Treatment of diseases: extrahepatic bile duct injury Indication Longmire surgery is available for: 1. Left hepatic duct stenosis, the hepatic duct above the stenosis is obviously dilated and has multiple stones, and can not be cleared through the hilar part, and the left hepatic lobe is obviously enlarged. 2. The left hepatic duct is stenotic, it is difficult to cut through the hilar stenosis, and there is no atrophy in the left hepatic lobe. 3. High bile duct injury, failure of multiple operations, extensive scar adhesion and separation of the hepatic hilum; difficulty in the horizontal section of the left hepatic duct; hepatic biliary angiography or intraoperative cholangiography confirmed the expansion of the left and right hepatic ducts Communicator. 4. Common hepatic duct stenosis, biliary cirrhosis, portal hypertension or portal vein variation affect the total stenosis of the common hepatic duct. Preoperative preparation 1. Detailed medical history, especially history of surgery and recurrent episodes of cholangitis. 2. Check liver, heart, and kidney function, and if necessary, do gastrointestinal barium meal or fiber gastroscope. 3. B-mode ultrasonography to understand hepatic bile duct dilatation, presence of stones and mites; if necessary, hepatic biliary tract photographic; then percutaneous transhepatic cholangiography (PTC) or endoscopic retrograde cholangiopancreatography (endoscopic) Retrograde cholangiopancreatography (ERCP) to obtain a clear biliary system X-ray image to identify the location of the biliary stenosis and the distribution of stones. 4. Give antibiotics to prevent and control lung or biliary infections. 5. Patients with jaundice should be injected intramuscularly or intravenously with vitamin K, and the original time of prothrombin should be determined. 6. Those with intestinal tsutsugamushi should be treated with sputum. 7. Place the gastrointestinal decompression tube and catheter before surgery. 8. Provide supportive care as appropriate, depending on the nutritional status of the patient. Surgical procedure Incision Generally, the right abdominis incision is used; if the right inferior oblique incision is used, it should be extended to the left rib. If you are not ready to dissect the hepatic hilum, in order to avoid the original incision adhesion, a midline incision is feasible. 2. Left hepatic lobe resection The hepatic round ligament, the falciform ligament, the left coronary ligament and the left triangular ligament were cut off, and the left hepatic lobe was dissociated. The left hepatic lobe was mostly resected, and the tangent was outside the confluence of the II and III hepatic ducts, about 3 to 4 cm to the left of the sacral ligament. The hepatic capsule was gradually cut upward from the lower edge of the liver, and the liver tissue was bluntly separated by a shank or a vascular clamp, and the blood vessel and the intrahepatic small bile duct clamp were cut and sutured one by one. The vascular clamp on the vascular pedicle of the left hepatic duct was released, and the hepatic artery and the portal vein branch were properly sutured and ligated. The forks of the II and III segments of the hepatic duct were cut open, and the 3-0 line was sutured to form a trumpet shape to expand the diameter of the intrahepatic bile duct. Pay attention to clear the intrahepatic bile duct stones. 3. Left hepatic bile duct jejunum end-to-side anastomosis 3 to 5 cm away from the jejunal rupture end, the intestinal wall was cut longitudinally on the lateral edge of the mesentery, and the incision was equal in size to the flare of the left intrahepatic bile duct. The jejunal musculocutaneous layer and the posterior margin of the left hepatic lobe were sutured intermittently with a No. 0 silk thread, and then the posterior wall of the anastomosis was sutured with a 3-0 line of full-thickness single-layer suture. The T-shaped drainage tube or the medical latex tube is placed in the intrahepatic bile duct, and the drainage tube is sutured with the anterior wall of the left intrahepatic bile duct with a fine needle thread, and the drainage tube is taken out through the jejunum. Continue to suture the anterior wall of the anastomosis with a 3-0 line. Finally, the jejunal muscle layer was sutured intermittently with the leading edge of the liver or the falciform ligament. 4. Rinse the surgical field repeatedly and place drainage under the left ankle. complication Underarm infection It is more common after hepatectomy and biliary anastomosis. We analyzed 220 cases of hepatolithiasis and stenosis, 15 cases of subgingival infection (6.8%), and 9 cases (20.9%) of underarm hepatectomy and biliary anastomosis. The reason: 1 liver section of the liver tissue suture, causing ischemia and necrosis, and even the formation of bile leakage, are conducive to bacterial growth and reproduction; 2 hepatobiliary stricture bile duct bile often contains a large number of bacteria, often caused by liver lobe resection , and biliary anastomosis increased the chance of pollution; 3 abdominal wall drainage incision is too small or too far from the surgical field or drainage is too early; 4 liver section bleeding, underarm blood; 5 liver section, surgical field cleaning is not sufficient. 2. Residual stones Hepatobiliary stenosis often associated with intrahepatic bile duct stones, residual stones occur: 1 intrahepatic bile duct structure, anatomical variation, stone distribution; 2 no clear biliary X-ray; 3 surgery lack of clinical experience, surgical choice Improper; 4 severe cholangitis emergency surgery; 5 intrahepatic bile duct multiple stones, lack of necessary intraoperative cholangiography or choledochoscopy after stone removal; 6 lack of necessary stone removal equipment. 3. Biliary bleeding Biliary hemorrhage after biliary anastomosis is caused by injury of bile duct arteries. Common causes: 1The needle is damaged by the small arteries on the bile duct wall, forming a pulsatile hematoma, and ruptures into the bile lumen; 2 needle injury The right hepatic artery wall or the hepatic artery wall gradually forms a pseudoaneurysm and collapses into the bile duct cavity; 3 hepatic bile duct is repeatedly explored, stoned, washed, causing bile duct mucosal damage or roughing damage caused by hepatic bile duct wall False road caused hepatic parenchymal hemorrhage. Careful surgical operation, biliary bleeding can be avoided. 4. Biliary infection Stenosis of the anastomosis, residual stones in the intrahepatic bile duct above the anastomosis or unobstructed T-shaped drainage tube are the main causes of biliary infection. 5. Bile leakage Bile leakage occurs due to cholangeal anastomosis suture detachment, excessive suture length of the suture, or poor drainage of the T-tube. The placement of T-tube drainage in the biliary anastomosis can reduce or avoid the occurrence of bile leakage.