Bilateral hepatocholangiojejunostomy

Bilateral hepatic bile duct jejunostomy is used for the treatment of hepatic bile duct stricture. When the high hepatic bile duct jejunum anastomosis, the surgeon is most troublesome: 1 high hepatic bile duct stricture with biliary cirrhosis, portal hypertension. 2 Hepatic ducts with longer hepatic bile duct stenosis and above stenosis have no obvious expansion. 3 In the previous operation, the biliary dilator was used to expand the stenosis of the hepatic bile duct, causing multiple rupture of the hepatic bile duct stenosis, or the T-shaped tube was not supported for a long time, causing the hepatic bile duct to be filled with granulation tissue and no normal bile duct. Mucosa. 4 secondary sclerosing cholangitis after biliary anastomosis. Curing disease: Indication 1. The left and right hepatic duct openings are narrow, and the intrahepatic bile duct is obviously dilated above the stenosis. 2, left and right hepatic duct stenosis is longer, the intrahepatic bile duct is more dilated than the stenosis, and there is no obvious hepatic lobe atrophy 3, the left and right hepatic ducts with mild stenosis combined with intrahepatic bile duct multiple stones. 4. The left and right hepatic ducts and their secondary hepatic duct openings are narrow. Preoperative preparation 1, detailed medical history, especially the history of surgery and recurrent episodes of cholangitis. 2, check liver, heart, kidney function, if necessary, do gastrointestinal sputum meal or fiber gastroscope. 3, B-mode ultrasound examination, understanding of hepatic bile duct dilatation, presence of stones and mites; if necessary, hepatic biliary tract photographic; then percutaneous transhepatic cholangiography (PTC) or endoscopic retrograde cholangiopancreatography (endoscopic Retrograde cholangiopancreatography (ERCP) to obtain a clear biliary system X-ray image to identify the location of the biliary stenosis and the distribution of stones. 4. Give antibiotics to prevent and control lung or biliary infections. 5, those with jaundice should be intramuscular injection or intravenous infusion of vitamin K, and determine the original time of prothrombin. 6, those with intestinal tsutsugamushi disease should be treated with sputum. 7, placed gastrointestinal decompression tube and catheter before surgery. 8. Provide supportive care as appropriate, depending on the nutritional status of the patient. Surgical procedure 1. Separate upward along the anterior wall of the common bile duct, reveal the junction of the common hepatic duct and the left and right hepatic ducts, and cut the common bile duct and the common hepatic duct longitudinally. 2. Explore the left and right hepatic duct openings and their stenosis, and separate them along the anterior wall of the left and right hepatic ducts, and cut the left and right hepatic duct stenosis. Usually the length of the left hepatic duct is 1.40 ± 0.75 cm, and the right hepatic duct is 0.84 ± 0.56 cm. 3, the left and right hepatic duct stenosis is long, the full incision of the right hepatic duct stenosis often requires partial hepatectomy in the hilar to reveal the right hepatic duct. 4, left and right hepatic duct incision, hepatic bile duct plastic suture. 5, liver lobe resection and left and right hepatic stenosis incision: adapted to the left and right hepatic duct stenosis with hepatic square lobe; right hepatic duct and its grade II hepatic duct and left hepatic duct stenosis. Cut the round ligament and the falciform ligament and pull the liver downward. The hepatic hilum is blocked, and the left hand finger of the surgeon is placed at the hilum to protect the left and right hepatic ducts and portal veins. Left tangential line: the hepatic capsule was cut 0.5 to 1.0 cm from the right side of the falciform ligament, and the bridge between the hepatic lobe and the left hepatic lobe was cut in the dirty surface and cut in the right side of the left sagittal sulcus. The liver capsule, bluntly separating the liver tissue, can be seen in the portal vein, sagittal and angular branches. Cut it and ligature it to reveal the lateral section of the left hepatic duct. Right tangential line: the hepatic capsule is cut through the gallbladder fossa and the left and right lobe of the liver and extends to the sacral surface, which is equivalent to the confluence plane of the left and right hepatic ducts of the hepatic hilum. The liver tissue is bluntly separated, and the left lower genus of the hepatic vein is seen. Ligation, revealing the right hepatic duct. The hepatic hilar block was removed, and the blood vessels and small bile ducts of the liver section were sutured one by one. 6. Cut the common hepatic duct and the left and right hepatic duct along the common bile duct incision. If necessary, the grade II hepatic duct can also be cut, and the hepatic bile duct can be sutured, and then the hepatic bile duct jejunostomy can be performed. After the anastomosis of the gallbladder was completed, the liver section was again examined for bleeding and bile leakage. The liver section was fully cleaned, and the omentum was opened from the central part, half of which was covered on the liver section, and the periphery was fixed with fine needle sutures. Place the drainage and T-tubes and poke through the abdominal wall. complication 1, underarm infection It is more common after hepatectomy and biliary anastomosis. We analyzed 220 cases of hepatolithiasis and stenosis, 15 cases of subgingival infection (6, 8%), and 9 cases (20, 9%) of left aneurysm resection and biliary anastomosis. The reason: 1 liver section of the liver tissue suture, causing ischemia and necrosis, and even the formation of bile leakage, are conducive to bacterial growth and reproduction; 2 hepatobiliary stricture bile duct bile often contains a large number of bacteria, often caused by liver lobe resection , and biliary anastomosis increased the chance of pollution; 3 abdominal wall drainage incision is too small or too far from the surgical field or drainage is too early; 4 liver section bleeding, underarm blood; 5 liver section, surgical field cleaning is not sufficient. 2, residual stones Hepatobiliary stenosis often associated with intrahepatic bile duct stones, residual stones occur: 1 intrahepatic bile duct structure, anatomical variation, stone distribution; 2 no clear biliary X-ray; 3 surgery lack of clinical experience, surgical choice Improper; 4 severe cholangitis emergency surgery; 5 intrahepatic bile duct multiple stones, lack of necessary intraoperative cholangiography or choledochoscopy after stone removal; 6 lack of necessary stone removal equipment. 3, biliary bleeding Biliary hemorrhage after biliary anastomosis is caused by injury of bile duct arteries. Common causes: 1The needle is damaged by the small arteries on the bile duct wall, forming a pulsatile hematoma, and ruptures into the bile lumen; 2 needle injury The right hepatic artery wall or the hepatic artery wall gradually forms a pseudoaneurysm and collapses into the bile duct cavity; 3 hepatic bile duct is repeatedly explored, stoned, washed, causing bile duct mucosal damage or roughing damage caused by hepatic bile duct wall False road caused hepatic parenchymal hemorrhage. Careful surgical operation, biliary bleeding can be avoided. 4, biliary infection Stenosis of the anastomosis, residual stones in the intrahepatic bile duct above the anastomosis or unobstructed T-shaped drainage tube are the main causes of biliary infection. 5, bile leakage Bile leakage occurs due to cholangeal anastomosis suture detachment, excessive suture length of the suture, or poor drainage of the T-tube. The placement of T-tube drainage in the biliary anastomosis can reduce or avoid the occurrence of bile leakage.