segmentectomy

Hepatic segmentectomy is used for the surgical treatment of hepatolithiasis. Hepatic bile duct stones were treated with partial hepatectomy. In 1958, Professor Huang Zhiqiang first created it. More than 40 years of practice has proved that partial hepatectomy for hepatolithiasis, combined with the double effect of relieving hepatic duct obstruction (calculus, especially the presence of hepatic bile duct stricture) and removing purulent infection, effectively improved the liver and gallbladder in China. Long-term treatment effect of tube stones. This experience has been unanimously affirmed. The theoretical basis for the treatment of intrahepatic bile duct stones with hepatectomy is the deep understanding of hepatobiliary stones and/or stenosis, long-term observation and research. Due to the presence of obstruction factors such as stones and/or stenosis, recurrent purulent infection of the intrahepatic bile duct not only aggravates the occlusion of stones and stenosis, but also aggravates the damage of liver parenchyma, leading to liver fibrosis and atrophy; Prone to bacteremia, septic shock, biliary hepatic abscess, bile duct ulcer caused by biliary bleeding, late stage lesions can occur a series of serious consequences such as biliary cirrhosis, portal hypertension. Partial hepatectomy removes the part of the liver tissue that has been severely damaged by obstruction and infection. The benefits are far superior to intrahepatic bile duct stones removal and are an important part of the surgical treatment of hepatolithiasis. In the first military and biliary surgery of the Third Military Medical University, 66 patients who underwent surgery and long-term (mean 8 years) follow-up were treated with partial hepatectomy, and 58 patients with excellent efficacy were 96.6%. In another group of the hospital from July 1975 to July 1989, 270 patients were followed up for 1 to 13 years, and the long-term efficacy was 84.6%. The surgical mortality rate was 1.8%, indicating the important position and role of partial hepatectomy in the surgical treatment of hepatolithiasis and stenosis. Treatment of diseases: liver fibrosis Indication The current indications for the use of partial hepatectomy for hepatolithiasis are more active, flexible and extensive than they were more than 30 years ago. This is due to the deepening of the understanding of the disease and the evaluation of the efficacy of various surgical methods. As a result of the development of surgical techniques, the main surgical indications are: 1. Hepatobiliary stones that are confined to one side or one leaf are difficult to be cleared by general techniques. 2, one or one lobe bile duct stones and (or) stenosis, accompanied by fibrosis of liver tissue, atrophy. 3, one or one lobe bile duct stones and / or stenosis, accompanied by multiple liver abscess or hepatic tube empyema, gallbladder (internal, external) fistula formation. 4, pan-hepatic bile duct stones, with more concentrated one side or more serious liver damage, one side of the liver can be partially removed, the other side of the stone removal surgery. 5, located in one side or a leaf of the intrahepatic bile duct with stones. 6, limited to a liver segment of the hepatic bile duct stenosis and / or stone. 7, one side or one leaf hepatobiliary stenosis, stones or cystic dilatation with cancer. 8, hilar bile duct stones and (or) stenosis in order to reveal, dissect the hilar structure, need to remove hyperplasia, swelling Part of the liver left lobe. Contraindications 1, hepatolithiasis, in the state of severe acute cholangitis, especially with bacteremia, septic shock, decompression, drainage surgery should be performed first, it is not appropriate to rashly perform partial hepatectomy. 2, advanced cases, patients with biliary cirrhosis, portal hypertension, before the first decompression, drainage, reduce portal pressure, it is not appropriate to first perform partial hepatectomy. 3, long-term obstructive jaundice, chronic dehydration, electrolyte imbalance, and patients with obvious coagulation dysfunction of hepatolithiasis, before the effective correction and drainage, the first complete partial hepatectomy is very dangerous. 4, due to long-term obstruction of one side of the bile duct, liver fibrosis, atrophy, resulting in a leaf or one side (semi-hepatic) liver tissue has reached the state of "self-removal", if there is no stone or infection, no need Partial liver resection. 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. Replenish 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 in order 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 emergency response ability of the body, which helps to smoothly pass 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 tubes, 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. 8. Analyze past imaging data to determine the surgical approach. 9, handle the abdominal wall sinus. 10, before the operation to do iodine allergy test. Surgical procedure 1. First define the extent of the diseased liver segment and the location of the intrahepatic bile duct. This can be done by: 1 careful analysis of preoperative angiography (T-tube angiography, ERCP, PTC, MRCP); 2 intraoperative B-mode ultrasound to distinguish and guide the pathological bile duct and corresponding liver segment; 3 lesions intravascular injection Methylene blue and other methods are displayed to help clear. 2, II, III, IV segment resection, should cut the round ligament, falciform ligament, left coronary ligament, left triangular ligament, fully free left hepatic liver; V, VI, VII, VIII liver segment resection, should cut off the liver The ligament, the sacral ligament, the right coronary ligament, and the right triangular ligament are fully freed from the right hemisphere. 3. Control of liver blood flow. Three methods are commonly used: 1 dissecting the hepatic hilum, blocking the hepatic blood flow to the left and right hemispheres in the left and right corners of the transverse hepatic sulcus, to control most of the hemorrhage during the resection of the left and right hepatic segments; 2 intermittently blocking the hepatic hilum Partial hepatic blood flow, in patients without cirrhosis, each time can be about 20min; 3 modified whole liver blood flow block, which is limited to the use of liver VII, VIII segment resection. 4. When the liver is broken, the scope of the resection should be determined according to the actual situation of the patient. Section II and III resection should protect the sagittal part of the portal vein; IV segment resection should protect the sagittal and hepatic veins of the portal vein; V and VIII resection should pay attention to protect the middle hepatic vein and right hepatic vein; Section VI and VII should be protected. Right hepatic vein. When the IV, V, VI, VII, and VIII segments are removed, the posterior inferior vena cava should be protected. 5, the liver section should be sufficient to stop bleeding, and prevent bile leakage, covered with omentum and placed drainage. 6. When the segment II (upper left hepatic lobe) is removed, the left outer leaf needs to be fully dissociated. According to the boundary between the lesion and its adjacent liver tissue, the segment II is removed under the control of left hepatic blood flow. The bile duct and hepatic vessels should be properly ligated, and the wound can be sutured without left suture. 7, III segment of the liver tube stones, because of its shallow position, it is generally easier to handle. However, in the implementation of stage III hepatectomy, the left triangular ligament and the left hepatic ligament should still be cut off, so that the left outer lobe of the liver is fully free, which is conducive to the operation. 8. Surgical treatment of intrahepatic bile duct stones in segment VI is difficult because of its deep location and often associated with hepatic duct stenosis of the right posterior hepatic lobe. The resection of the liver should first cut the right triangular ligament and right coronary ligament, free liver right Leaves, in the right liver pad with a yarn pad, so that the VI segment can be better exposed. Under the control of hepatic blood flow, according to the lesion range of the stone and the liver, the right posterior lobe of the liver (section VI, VII) or VI is removed, and the tube on the liver section is properly ligated, covered with omentum and placed in the abdominal cavity. .