End-to-end anastomosis of extrahepatic bile duct and jejunum

Biliary stenosis and bile duct stenosis, and some are congenital malformations, but most of them are caused by accidental injury. Bile duct defect reconstruction can be divided into two categories: one for small bile duct defects, such as partial bile duct repair, bile duct end-to-end anastomosis; the other for larger bile duct defects, such as bile duct duodenal anastomosis Surgery, extrahepatic bile duct injury and stenosis repair. Bile duct construction is more complicated and difficult, and the indications should be strictly controlled according to the patient's condition. Due to the difficulty in re-construction of the bile duct, it is necessary to complete the first-stage operation. It is divided into two phases only when necessary. The first stage drains the bile duct and the second stage constructs the bile duct. Treatment of diseases: bile duct stones Indication 1. Due to bile duct disconnection caused by surgery or trauma, end-to-end bile duct anastomosis should be performed immediately. 2. Due to multiple operations of stones and chronic inflammation, scars are scarred, and scar removal and bile duct construction should be performed. 3. A small number of congenital extrahepatic bile duct stricture or atresia can also communicate with the biliary tract and intestine through bile duct reconstruction. Preoperative preparation 1. Patients with bile duct defects, the condition is often complicated, and the medical history must be detailed. Cholangiography should be performed before surgery to determine the location of the bile duct and the degree of defect in order to select a suitable procedure. 2. Patients often have jaundice, anemia, weight loss, and dehydration; at the same time, the operation time is longer and needs to be fully prepared before surgery. See the common bile duct incision for specific preparation. 3. Make intraoperative angiography and choledochoscopy preparation. Surgical procedure 1. Common stenosis of the common bile duct Often due to the removal of the gallbladder, the cystic duct traction is too tight, caused by a part of the common bile duct wall. The patient took the supine position. The biliary tract is revealed through the right superior rectus abdominis incision. After the diagnosis is confirmed, a small longitudinal incision is made in the stenosis, or the stenosis is wedge-shaped. Then, the suture was splayed with a 0-gauge wire. A small incision was made in the anterior wall of the proximal common bile duct, and a t-shaped tube was placed as a stent, and the suture was interrupted by a thin wire. After the examination without bile leakage, the cigarette drainage was placed at the repair site, and the t-shaped drainage tube was taken out from the same side abdominal wall as a small incision, and then the abdominal wall was sutured according to the layer. 2. Common bile duct end anastomosis When the common bile duct is mistakenly cut, cut, or the defect is short, the common bile duct can be trimmed or partially excised, and the end of the common bile duct anastomosis can be performed to restore the normal anatomical relationship of the biliary tract and retain the sphincter. (1) Separation of the duodenum: After the common bile duct is fully exposed, the posterior peritoneum of the second part of the duodenum is cut open, and the duodenum is slightly separated to ensure no tension after the common bile duct anastomosis. (2) Stitching traction line: a traction line is laid at the upper and lower ends of the common bile duct or the bile duct. (3) Resection of the stenosis: removal of the stenosis of the common bile duct (if the gallbladder should be removed at the same time). (4) anastomosis: simple external eversion and intermittent anastomosis at both ends of the common bile duct. (5) T-shaped tube: a small incision is placed at the upper end or the lower end of the anastomosis to place a t-shaped tube for internal support, and then the suture is tightly interrupted by a thin wire. 3 common bile duct duodenal anastomosis In the lower end of the common bile duct, the defect is longer, the fibrosis is in the form of a strip, and the upper end of the common bile duct can be separated. However, when the end of the common bile duct is difficult, the upper part of the duodenum can be fully separated and the common bile duct can be performed. Intestinal anastomosis. The anastomosis procedure was performed with the common bile duct end of the common bile duct. 4 extrahepatic bile duct injury and stenosis repair Extrahepatic bile duct injury and stenosis repair may be used when the duodenum is difficult to separate, or the duodenum has lesions that cannot be anastomosed to the common bile duct. Generally, the common hepatic duct or the left and right hepatic ducts are y-shaped with the upper part of the jejunum to prevent retrograde infection of the biliary tract. This operation is often used for extensive stenosis or defect of the common hepatic duct or common bile duct, and duodenal adhesion is fixed. (1) Isolation of the hilar bile duct: carefully separate the hepatic portal or left and right hepatic ducts, remove the scar tissue, and try to retain the common hepatic duct and the left and right hepatic ducts. If the left and right hepatic ducts are close together, the anterior and posterior walls of the left and right hepatic ducts can be sutured to each other, and the sutured left and right hepatic duct walls can be cut to form a new hepatic duct. Or try to keep the posterior wall of the common hepatic duct and the left and right hepatic ducts, and repair the anterior wall to be oval. The anastomosis of the common hepatic duct and the posterior wall of the left and right hepatic ducts was used as the posterior wall of the anastomosis, and the jejunum of the anastomosis was used as the anterior wall (2) Cutting the upper part of the jejunum: Cut the jejunum about 15 cm away from the duodenal suspensory ligament in the upper part of the jejunum, and cut the mesentery to the proximal root. Be careful not to damage the mesenteric blood supply. After the distal end of the jejunum is closed with two layers of suture, it is lifted from the transverse colon before or after the hepatic hilum for anastomosis. (3) bile duct jejunal anastomosis: the distal end of the jejunum raised to the hepatic hilum is first sutured on the scar tissue on the posterior side of the hilar. Then cut a small mouth in the side wall of the blind end of the jejunum, the size is equivalent to the liver port after the repair, and the jejunum and the liver tube are lined up with a single layer of eversion and anastomosed. The posterior wall of the anastomosis is sutured first, and then a suitable t-shaped tube or balloon catheter is placed in the anastomosis for stent drainage, and is taken out through a small incision in the distal part of the jejunum. A small incision of the drainage tube is taken out by suture the jejunum wall with a purse. The anterior wall of the anastomosis is then sutured. The two sides of the anastomosis were sutured with the liver capsule for 1 to 2 stitches. If the liver tube is too short or caliber, it is difficult to match the jejunum. The jejunal stump can be opened, and the whole mouth and the hepatic scar can be sutured. Only the bile duct can be inserted into the intestine. The omentum (the drainage tube is passed through the omentum) covers a small incision in the distal part of the jejunum, and the suture is fixed 1 to 2 needles. (4) End-to-side anastomosis of jejunal jejunum: End-to-side anastomosis was performed about 30 cm from the proximal end of the jejunum and the distal end of the jejunum from the jejunal jejunum. The outer layer was sutured with a thin silk thread as the sarcoplasmic layer, and the inner layer was sutured with a 3-0 gut or a 0-thread as a full-thickness interrupted inversion. Close the mesenteric gap to prevent internal hemorrhoids. (5) Place drainage: Place the cigarette drainage near the anastomosis of the bile duct jejunum, and take it out along the small incision from the right abdominal wall along the biliary drainage tube. Cigarette drainage was fixed with a safety needle, and the biliary drainage hose was fixed with a thread of 1 to 2 needles. The abdominal wall incision was sutured layer by layer.