Intrahepatic cholangiojejunostomy

Treatment of diseases: gallstones Indication 1. Extrahepatic bile duct stenosis can not be repaired in the hilar and bile duct jejunostomy due to technical reasons, and the left and right hepatic ducts still communicate with each other. 2. The left hepatic duct opening stenosis should not be performed in the left hepatic lobe. 3. Combined surgery for hepatolithiasis and stenosis. 4. Hepatic malignant tumors (primary or secondary) caused by extrahepatic bile duct obstruction should not be performed radical surgery. Contraindications 1. The bile duct bifurcation is blocked, and the left and right hepatic ducts do not communicate. 2. The majority of intrahepatic bile duct stenosis was not corrected. 3. Patients with advanced cancer are expected to have shorter survival time. 4. With severe obstructive jaundice, ascites, not suitable for surgical treatment. Preoperative preparation 1. The location and extent of biliary obstruction should be accurately estimated. It can be determined by non-invasive methods such as B-mode ultrasound, CT, MRCP, etc. If necessary, PTC and ERCP can be performed before surgery. However, care must be taken to prevent complications such as biliary infections and bile leakage. 2. If PTC and PTCD have been performed before surgery, surgery should be performed at an early stage. After 2 to 3 weeks, there may be a fatal biliary infection due to delayed surgery, and liver function cannot be achieved even after 2 to 3 weeks of drainage. restore. 3. Preoperative PTCD is generally only used in patients with severe obstructive jaundice and the general condition is too poor to perform surgery in time. Under drainage, care should be taken to avoid infection and loss of water and electrolytes. If it can be drained through the endoscope, the effect is better than PTCD. 4. Patients with obvious weight loss and malnutrition began to strengthen intravenous nutrition supplement 1 week before surgery to correct hypokalemia, hyponatremia, anemia, hypoproteinemia, and vitamin K11 supplementation. 5. Oral bile salt preparation. 6. Antibiotic bowel preparation. 7. Oral administration of ranitidine 150mg before surgery. 8. Stomach tube and indwelling catheter. 9. Prophylactic use of antibiotics, in view of patients with obstructive jaundice, acute renal failure may occur after surgery, should avoid the use of antibiotics such as Qingda toxins with nephrotoxicity. Surgical procedure 1. The choice of surgical incision is often determined by the specific patient. It is generally extended to the left side of the xiphoid process on the basis of the right inferior oblique oblique incision or the right rectus abdominis incision for biliary surgery to facilitate treatment of the left liver. Outer leaves; if you only plan to do left hepatic bile duct jejunostomy beforehand, you can also use the left inferior oblique incision to avoid surgical scars and intra-abdominal adhesions in the right upper abdomen and upper abdomen. 2. Separation of intra-abdominal adhesions, usually along the surface of the liver, first separate the front of the liver, and then along the liver surface to the dirty face, cut the sacral ligament and the round ligament, until the sacral ligament attachment of the diaphragm; To the left, cut the left coronary ligament, and then pull the left outer lobe of the liver downward. The stomach and spleen should be properly retracted with a large arc-shaped hook, and the left triangular ligament of the liver should be clamped and cut, and ligated. When cutting the left triangular ligament, care should be taken to avoid damage to the upper spleen of the spleen due to excessive pulling of the hook, and rupture of the capsule and bleeding; at the same time, the ligament of the triangular ligament should be ligated carefully to prevent the vascular clamp from slipping off, and the broken end is retracted. Hard to find. After the left outer lobe of the liver is free, pay attention to check whether there is bleeding on the diaphragm, and properly treat it. Fill the left axilla with a saline gauze pad. A typical Longmire procedure involves the complete removal of the left outer lobe of the liver, or the removal of the left outer lobe of the liver to find the left outer lobe. Generally, the liver tissue can be cut at a distance of 2 to 3 cm on the left side of the falciform ligament, so that a part of the liver tissue of the left outer lobe of the liver can be retained. 3. Approximately 2 cm along the left side of the falciform ligament, the hepatic capsule was incised, and the liver tissue was bluntly separated. The tubular structures in the liver parenchyma were cut and ligated one by one, as in the case of general hepatectomy. If the operation is performed for intrahepatic bile duct stones and hepatic bile duct stenosis, the bile duct of the left outer lobe of the liver is obviously dilated and thickened, and there are a lot of pigmented stones in the lumen. At this time, the bile duct needs to be cut to remove the stones, and then keep going. When the bile duct is obstructed, the hepatic artery is obviously dilated, and the arterial blood flow is increased. However, the blood flow of the portal vein is often reduced, especially when hepatic bile duct stones and stenosis are more obvious, so the hemorrhage on the liver section is often arterial hemorrhage; Hemorrhage of the hepatic bile duct end, from the dilated bile duct surrounding arterial plexus, the bleeding is also more severe, should be clamped one by one, sutured with a thin wire to stop bleeding. In most cases, the left lateral lobe hepatic duct is composed of the left outer upper segment (II segment) and the left outer segment (III segment) hepatic duct. When the intrahepatic bile duct is cut, it is generally 1 to 2 cm away from the bifurcation. The general cuff-shaped intrahepatic bile duct is reserved for plastic suture. 4. With a constant angle vascular clamp, extend from the segment II hepatic duct to the segment III hepatic duct opening, and then cut the bifurcation of the hepatic duct at this line, and cut the suture with a 4-0 absorbable synthetic suture. After opening the hepatic bile duct wall, after the plastic suture, the hepatic tube stump becomes a larger bell mouth, protruding from the liver section, making the intrahepatic bile duct jejunal anastomosis easy to perform, and also reducing the chance of anastomotic stenosis at the end of the operation. Generally, it is necessary to explore the hepatic hilum through the hepatic duct opening on the liver section, retrogradely remove the stone, expand the stenosis and collect the tissue for cryosection pathological examination. In the case of a left stenosis of the left hepatic duct and intrahepatic bile duct stones, the left inner lobe can be retrogradely explored through the hepatic duct stump and the stones removed. 5. The left hepatic lobes were completely hemostasis, the surgical field was cleaned, the saline section was filled with a saline pad, and the operation was turned below the transverse colon. Lift the transverse colon and find the beginning of the jejunum. According to the preparation method of Roux-en-Y intestinal fistula, the intestinal fistula is about 50cm long, the end is sutured, and the avascular region on the left lateral mesenteric membrane of the middle colonic artery. Pull up from the front of the stomach to the left lateral section of the liver for anastomosis. Close the gap between the mesas. The end of Roux-en-Y intestinal fistula was sutured to the left outer lobe section of the liver, and an opening was made to the mesenteric margin of the corresponding part of the intrahepatic bile duct opening to synthesize absorbable suture 4-0 (or 3-0). Silk thread) suture the mucosa with a single layer of intermittent mucosa at the end of the bile duct and the jejunum. After the posterior layer is anastomosed, a suitable silicone rubber tube with a side hole is placed in the direction of the hepatic hilum, and the anterior wall is sutured through the jejunum. The jejunum and the liver section were sutured and fixed, and the left inferior temporal region was placed and drained. complication 1. Hepatic left venous injury hemorrhage in the left hepatic lobe and left hepatectomy, such as poor surgical field exposure or excessive traction of the liver, especially when the left posterior superior venous tear or blood vessel ligation is not strong, the line Major bleeding can occur when the knot is detached and the vascular end is retracted. Do not blindly clamp or suture the hepatic left venous injury. Should accelerate the blood transfusion, press the blood vessel to break the blood vessel with the left hand, absorb the blood, and use the large curved needle at the proximal end of the vascular rupture together with part of the liver tissue. Sewing and ligation together can achieve the purpose of stopping bleeding. In order to avoid damage to the left hepatic vein, when the liver is cut over the left interlobular fissure, when the vein is exposed, the vascular clamp should be clamped together with part of the liver tissue on the trunk, and then cut and sutured. It can also be sutured through the suture at the vein main running position (corresponding to the extension of the ligament of the sacral ligament sacral attachment point 1cm), which can avoid damage to the blood vessel. 2. Lateral cholangitis, anastomotic stricture, intrahepatic bile duct stones can occur. 3. The development of hilar cholangiocarcinoma, along the bile duct expansion, can make the left intrahepatic bile duct jejunal anastomosis lost use.