right hepatic lobectomy

Right hepatectomy 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. The right hepatectomy for the treatment of the right hepatic duct and the stones in its main branches has certain characteristics: 1 due to stone obstruction and recurrent episodes of acute cholangitis, the right lobe of the liver and its adjacent surrounding tissues such as hernia and colon right , the right adrenal gland, the posterior inferior vena cava, etc. have extensive and dense adhesions; 2 long-term obstruction of the right hepatic duct or its main branches and recurrent infection often lead to extensive damage to the right liver, fibrosis of the portal area, leading to the corresponding liver The atrophy of the tissue; 3 the compensatory increase of the left lobe liver tissue, the liver loses the normal shape and the ratio between the left and right leaves, and the following vena cava rotates clockwise in the clockwise direction, thereby causing the lesion The right lobe of the liver is pushed to the right rear, which makes the exposure and surgery difficult. 4 The right lobe of the liver does not show fibrosis and atrophy. Because it is much thicker than the left lobe of the liver, combined with inflammation and congestion, it causes time and trauma. Large, wide wounds, bleeding or bleeding, and postoperative complications. Therefore, when hepatic bile duct stone disease is performed in the right hepatic lobe resection, it requires both accurate positioning and skillful surgery. The selection of surgical indications should also be strictly controlled. From many aspects, it is necessary to strive for safe and smooth operation. The long-term effect is excellent. The incidence of intrahepatic bile duct stones in the right lobe is lower than in the left lobe, so the chance of resection of the right lobe is also reduced. In 320 cases of hepatectomy in the First Military Medical University, only 34 cases of right hepatectomy were performed, which was only 10.6% of the total number of hepatectomy, which was less than 1/8 of the left hepatectomy. Treating diseases: liver cancer 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. Hepatolithiasis limited to one side or one leaf, it is difficult to obtain a clearer by general techniques. 2. One or one of the hepatolithiasis and/or stenosis, accompanied by fibrosis of the liver tissue, atrophy. 3. One or one lobar hepatolithiasis and/or stenosis, accompanied by multiple hepatic abscess or hepatic duct empyema, bile (internal and 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, and the other side is treated with stone removal. 5. Intrahepatic bile duct dilatation with stones on one side or one leaf. 6. Hepatic bile duct stenosis and/or calculi confined to a liver segment. 7. One or one of the hepatic bile duct stenosis, stones or cystic dilatation with cancer. 8. Hepatic bile duct stones and (or) stenosis in order to reveal and 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, and partial hepatectomy should not be performed rashly. 2. In advanced cases, patients with biliary cirrhosis and portal hypertension should not undergo partial hepatectomy before decompression, drainage, and portal pressure reduction. 3. Patients with long-term obstructive jaundice, chronic dehydration, electrolyte imbalance, and hepatolithiasis with obvious coagulopathy, before the effective correction and drainage, the first partial liver resection is very dangerous. 4. Because of the long-term obstruction of one side of the bile duct, liver fibrosis, atrophy, the patient who has reached the "self-removal" state of one leaf or one side (semi-hepatic) liver tissue, if it does not combine stones 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. 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. 8. Analyze past imaging data to determine the surgical approach. 9. Handle the abdominal wall sinus. 10. Do an iodine allergy test before surgery. Surgical procedure 1. The patient's right side is 45° high, taking a long oblique incision from the xiphoid to the right midline of the right rib. After cutting the round ligament and the falciform ligament, the right rib arch is retracted with a combination hook. 2. Separate the adhesion between the right lobe of the liver and each tissue, and fully dissipate to the right of the liver. The right rear upper side should be close to the right side wall of the posterior inferior vena cava. 3. After the gallbladder is removed, the hepatoduoduus ligament and the hilar sac are separated and dissected, and the anatomical gallbladder plate is further separated to expose the right hepatic hilar. 4. If you can use the vascular anastomosis instrument such as heart ear pliers or inferior vena cava clamp to effectively clamp the right hepatic artery and right portal vein into the liver in the right corner of the liver transverse sulcus, you can use it to control right hepatic stenosis. Liver blood flow, reduce bleeding during liver disease, and keep the surgical field clear. If the right hepatic blood flow cannot be selectively controlled due to adhesion and contracture, the liver and duodenal ligament should be used to intermittently block the hepatic blood flow. 5. Hepatobiliary stones are benign lesions mainly caused by inflammation. Hepatectomy requires the removal of obstructed or dilated hepatic ducts and fibrotic and atrophic liver tissue due to stones, so as to eliminate the obstruction and remove the lesions. Fibrotic liver tissue often has a clear boundary. When the liver is broken, care should be taken to protect the middle hepatic vein, and only the right branch is cut off. The structure close to the posterior inferior vena cava of the liver does not need to be separated one by one, and the liver can be broken 1 to 1.5 cm from the inferior vena cava. 6. The liver section should be adequately hemostasis, and the large hepatic tube stump should be carefully closed after removing the stone. Cover the liver section with a large omentum and place drainage.