hepatobiliary exploration

Hepatolithiasis is often performed by incision of the common hepatic duct combined with the common bile duct. It requires a long and high hepatic common incision to facilitate the exploration of major hepatic and caudal hepatic duct openings under direct vision. And further explore the opening of the secondary hepatic duct, to understand the obstruction factors such as stones, stenosis and liver tube lesions. Hepatic bile duct exploration should be combined with the exploration of the liver. After separating the adhesion between the liver and the sputum, first observe the size and shape of the liver, the fibrous scar on the liver surface, and then retract the round ligament of the liver, and explore the right lobe of the liver with the left hand. The face of the leaf and the dirty surface, the left outer leaf was explored with the right hand, and the left and right hepatic ducts at both ends of the hepatic hilar and hepatic transverse fissure were touched. Large stones in the intrahepatic bile duct can be clarified when the liver is touched. Hepatic bile duct exploration can remove the stones in the hepatic hilar hepatic duct, the hepatic duct of the tail leaf and the secondary branch of the left and right hepatic ducts, but the treatment of intrahepatic bile duct stricture and stones above the secondary branch is limited. of. It is often necessary to combine other operations to meet the treatment requirements. Treatment of diseases: gallstone liver abscess Indication 1. Patients with recurrent acute suppurative cholangitis or hepatic cholangitis with or without jaundice, and imaging data showing patients with hilar or intrahepatic bile duct dilatation and stones. 2. Clinically diagnosed as biliary septic shock, biliary hemorrhage, liver abscess, and patients with hepatic bronchial fistula. 3. In the past, there was a history of hepatolithiasis surgery, and the postoperative clinical symptoms were repeated. 4. Repeated episodes of suppurative cholangitis after upper abdominal trauma, liver trauma, and hilar trauma. 5. Patients with obstructive jaundice, hilar and intrahepatic bile duct dilatation, stone formation or biliary formation after cholecystectomy. Contraindications 1. The clinical manifestations are hepatic jaundice, a history of hepatitis B infection or hepatitis B immunological examination, chronic liver parenchymal damage. 2. Imaging (B-ultrasound or CT, MRI) examination showed that there were strong light groups or calcification in the liver and the sound shadow was not accompanied by the distal hepatic duct dilatation. 3. Hepatic hilar or intrahepatic bile duct obstruction complicated with severe portal hypertension, patients who have not effectively reduced portal pressure. 4. Patients with a first hepatic portal infection or abscess without effective drainage. Preoperative preparation Hepatolithiasis, hepatobiliary stenosis, especially those with recurrent seizures of severe cholangitis, long-term obstructive jaundice and biliary fistula, local and general conditions are often poor, and should be carried out at the same time as various examinations and diagnoses Thoughtful preoperative preparation. 1. Supplement blood volume, maintain water and salt metabolism and acid-base balance, especially pay attention to the correction of chronic water loss and hypokalemia. 2. Strengthen and improve the systemic nutritional status of patients. Give a high-protein, low-fat diet and add enough calories and vitamins. Patients with obstructive jaundice should be injected with vitamin K11. Some patients also need fluid replacement and blood transfusion. In patients with complete biliary fistula and hepatic insufficiency, intravenous nutritional support is often required. 3. Check the coagulation mechanism and correct any abnormalities that may occur. Comprehensive analysis was performed together with the results of liver function tests to evaluate liver reserve and metabolic function. 4. Pay attention to protect liver function. Repeated episodes of biliary tract infection and prolonged obstructive jaundice often cause varying degrees of liver damage. If you have biliary cirrhosis, you should pay attention to active liver protection. Patients with long-term external drainage tube, if the daily bile flow is many and the color is light, it is often a sign of liver dysfunction. The inversion of the ratio of white and globulin indicates that the compensatory function of the whole liver is in an unfavorable condition. If you have splenomegaly and ascites, you should first do liver protection treatment. After you have improved, consider the staged treatment. 5. Investigation of bile bacteriology and antibiotic susceptibility testing to use antibiotics more rationally. In some complicated cases, it is often necessary to start systemic application of antibiotics 2 to 3 days before surgery to help prevent surgery or angiography and stimulate cholangitis. If the operation is performed during the onset of cholangitis, penicillin or metronidazole (metidazole) should be administered to control the mixed infection of anaerobic bacteria. 6. Protect and support the body's emergency response capabilities to help smooth out the post-operative traumatic response. These patients have been repeatedly attacked by biliary tract infections and multiple operations, often with physical depletion; and most of them have a history of treatment with different degrees of glucocorticoids, systemic response is low, should pay attention to support and protection. In the operation, hydrocortisone 100 ~ 200mg was intravenously instilled, and 50-100 mg per day can be instilled within 2 days after surgery, which often receives good results. 7. For patients with external drainage, the preparation of the skin of the mouth should be carried out as soon as possible. For excessively long granulation tissue, it should be cut off. For local inflammation and skin erosion, the dressing should be changed frequently and wet if necessary. For mouthwashes with digestive juices, apply zinc oxide paste coating protection. Keep your mouth clean and perform surgery when your skin is healthy. Deworming should be routinely performed after admission. Stomach tubes and catheters should be placed before surgery. Surgical procedure 1. Incision: The surgical approach for hepatic bile duct exploration is affected by many factors, mainly: (1) The number of previous operations. In patients who have had multiple operations in the past, the upper abdomen or the right upper abdomen often have interdigitated rectus abdominis incisions and right inferior oblique incisions, and a few have transverse incisions. If other laparotomy procedures have been performed in the past due to intra-abdominal complications, such as intestinal adhesion lysis, abscess drainage, etc., there will be many post-operative incision scars in the upper abdomen and right upper abdomen, so that the choice of re-surgical incision, Very difficult. (2) The healing of abdominal incisions in the past. If there are abdominal infections, biliary or intestinal fistula, abdominal wall incision infection, abdominal wall wound rupture or biliary drainage tube directly from the incision after surgery, it is easy to cause infection of the abdominal wall incision, wound fissure or abdominal wall incisional hernia. These also increase the complexity of re-surgical incision selection. (3) The current location of the biliary lesion and the problems that need to be solved in this operation are the most important factors in determining the choice of incision. Surgery involving the intrahepatic bile duct and liver requires extensive exposure, requiring the incision to be operated under direct vision; for the lesion of the right posterior hepatic duct, it is often necessary to consider the incision of the chest and abdomen. (4) Changes in the size and shape of the liver. The obstruction of the main bile duct opening in a certain half of the liver is often caused by irregular atrophy and deformation of the liver due to atrophy of the disease side and contralateral hyperplasia. This factor should also be considered when selecting a reoperation incision. (5) Whether there is cirrhosis or portal hypertension. Biliary cirrhosis, portal hypertension, in addition to extensive collateral circulation in the abdomen, the incision scar of previous surgery is often an important portal-body vein communication site, with a large number of collateral circulation. Therefore, the incision should be determined according to the condition of each patient. The currently most commonly used incision to meet the needs of surgical operations is the oblique incision of the right upper abdomen. Generally 2 fingers under the cost of the rib, the length is determined according to needs. 2. The display of the hilar bile duct. Hepatolithiasis is often performed by incision of the extrahepatic bile duct. The main hepatic duct must be fully exposed and directly in front of the left and right hepatic duct bifurcation, and the incision of the common bile duct is extended to the common hepatic duct. 3. The extrahepatic bile duct incision can be seen through the left and right hepatic duct bifurcation. The hepatic duct opening of the left and right hepatic duct and caudate lobe can be seen under direct vision to facilitate the exploration of the hepatic bile duct. 4. Using a gallstone spoon, one pair of left and right hepatic ducts, and the hepatic duct of the tail leaf were explored, combined with preoperative examination to confirm the location and extent of hepatolithiasis and stenosis. 5. Remove the stones located at the common hepatic duct opening, left and right hepatic duct openings or primary and posterior hepatic ducts. 6. After the end of the exploration, a proper size T-shaped tube is placed in the common bile duct to drain the biliary tract, which can avoid bile leakage. It can be used for retrograde cholangiography 2 weeks after operation to understand the patency of the intrahepatic bile duct. No residual stones. If there are residual stones, the T-tube drainage channel can be used as a way to remove stones from the choledochoscope. complication 1. Acute attack of cholangitis. Mainly due to repeated long-term exploration or stone removal, inappropriate biliary flushing and other irritations, cholangitis attacks, and even septic shock. 2. Bile leakage. May be due to: 1 bile duct incision or T-shaped tube is not tightly sutured; 2 reactive edema, spasm, and excretion after distal exit of bile duct; 3 intrahepatic bile duct stones or residual extrahepatic bile duct stones, distal bile duct obstruction . The former two are treated in a short period of time, and most of them can be eliminated; the latter often cannot be pinched, and it is still necessary to perform fiberoptic choledochoscopy after taking an angiographic observation to remove stones and relieve obstruction. If the distal stone is incarcerated, the tube cannot be removed until it is effectively treated. 3. Under the liver or under the armpit abscess. Mainly because the perihepatic effusion, hemorrhage and bile were not absorbed before the closure of the abdomen; no drainage or drainage failure was left. This situation, as long as it is noted, is generally less common.