Hepatobiliary Pelvic Biliary Intestinal Drainage

Hepatobiliary calculi and stenosis are the main reasons for the current implementation of intrahepatic drainage. In the case of intrahepatic bile duct stones with stenosis, the method of extensively revealing the intrahepatic bile duct is used to cut and shape the stenosis to form a "hepatic bile duct", and then drainage with the intestine. This is a new surgical approach that can address stenosis and biliary retention, reducing the possibility of residual stones and recurrence. Treatment of diseases: gallstones Indication 1.1 to 3 grade hepatic stenosis, stenotic proximal saclike dilatation, filled with massive and mud-like stones. 2. Extrahepatic bile duct dilatation, thickening of the wall, there is a typical history of recurrent episodes of charcot's triad, indicating continuous stone formation, continuous stone discharge; In addition, there are many intrahepatic bile ducts, it is impossible to level 3 or above during surgery. The bile duct exploration revealed that the stone could not be completely removed. 3. Recurring stones and residual stones in the biliary tract. Internal drainage can avoid the adverse effects of multiple operations and t-tubes. At the same time, because the problem of poor bile drainage is completely solved, the effect of preventing postoperative stone regeneration is far better than temporary external drainage. For hepatic duct stones that cannot be removed, as long as the hepatic stenosis in the liver is satisfactorily treated, the stones falling from the upper hepatic duct into the common bile duct can be quickly discharged without causing biliary obstruction. Contraindications 1. Acute cholangitis, bile duct stiffness, thickening, severe inflammation and edema. 2. Biliary fibrosis, bile duct mud-like stones. 3. The stone is confined to a section of the liver for local excision. 4. Accumulating intrahepatic stones, without intrahepatic bile duct stricture, confirmed by surgery to remove the stones during surgery. Preoperative preparation Due to the wide range of operation of the hepatic bile duct drainage, the time is long and the physiological disturbance is large. Preoperative preparation should be more adequate. 1. The same bile duct jejunum roux-y anastomosis. 2. Serum albumin reaches 35g/l or more. 3. Prepare blood for 1000ml. 4. Indwell the catheter. Surgical procedure 1. Position: supine, slightly higher back and right back, and aligned with the operating table bridge. 2. Incision: J-shaped incision in the right upper abdomen, from the left side of the xiphoid process to the white line, 3cm to the right on the umbilicus, 11 tibial tip can also use t-shaped incision. It is better to cut with an electric knife when biliary surgery is performed again. The cutting edge should be carefully protected and kept dry to prevent wet immersion pollution. 3. Explore and reveal the level of hepatic hilar into the abdominal cavity, explore the liver, spleen, gallbladder, pancreas and gastrointestinal conditions, determine the surgical style. Because many cases are re-operations, or multiple operations. The upper right abdomen area often has extensive adhesions, making it difficult to reveal. Exposing the first-stage hepatic hilum is the first pass into the liver; and the perihepatic adhesions are the first to reveal the hilar. The first thing to do is to find the common bile duct and then go up to the hilum. To this end, according to the specific conditions, the following routes are available: 1 in front of the duodenal bulb to the front of the common bile duct; 2 follow the cystic duct to the right wall of the common bile duct; 3 close to the right hepatic anterior lobe, the side of the lobes Next, follow the second segment of the duodenum, the upper right edge of the first segment reaches the retina hole, find the common bile duct; 4 the duodenal ligament has been revealed, can be puncture from right to left, extract bile to determine the common bile duct; Gastric sinus, pyloric ring, the upper edge of the duodenal bulb, the common bile duct; 6 incision of the liver and stomach ligament, to the right of the posterior wall of the antrum to the right into the retinal hole, after communication to reveal the common bile duct; 7 through the duodenum Open, through the Oddi sphincter insertion probe into the common bile duct; 8 through the t-shaped tube into the common bile duct; 9 bile duct jejunum roux-y after surgery, can cut open the jejunum in front of the anastomosis, the common bile duct is revealed through the anastomosis. When looking for a common bile duct and revealing a primary hepatic hilum, it is often necessary to loosen the adhesion. Separation and adhesion should be based on the characteristics of adhesion, and the corresponding separation method should be adopted. In general, sharp separation is used for perihepatic adhesions. The denser the adhesion, the sharper the separation. Before decomposing adhesions, the tissues and organs of the adhesion block should be identified. When the adhesion of the gallbladder, intestine and other hollow organs is loosened, the serosa and muscle layers should be distinguished. When separating this adhesion, the operator's left hand index finger and thumb should be squeezed, the muscle layer is pushed open, and the adhesive tape is cut and separated in the subserosal space. When separating the adhesion of the subhepatic space, it should be carried out close to the liver surface. When the dense adhesion between the intestine and the liver is decomposed, it is necessary to pay attention to the preservation of the integrity of the intestine, and if necessary, it can be peeled off under the liver capsule. When the tunnel adhesion is decomposed, it should be closely attached to the tunnel, and guided by the duct placed in the tunnel, from loose to dense, from easy separation to difficult separation, clear vision, and step by step. Once the bowel is ruptured, it is repaired. 4. Cholecystectomy: If the gallbladder is not removed, it should be removed. The gallbladder bed is not closed, so that the right 1 to 3 grade liver canal is incision. 5. Incision and treatment of common bile duct lesions in the first segment of the common bile duct suture two needle traction line, after the puncture of the bile, the longitudinal bile duct was cut open, the common bile duct stones were removed, and the sphincter sphincter was passed through several biliary spons. , flushing smoothly. The 6.1 to 3 grade hepatic incision 1 to 3 hepatic duct incision and the establishment of hepatobiliary tube are the core of surgical treatment of hepatolithiasis and stenosis. The common hepatic duct is cut upward from the common bile duct incision, including the subsequent exposure of the intrahepatic bile duct. The basic techniques are guidance, side seam, side ligature, side cut, side pull and puncture. Left hepatolithiasis accounts for 60% to 85% of the entire hepatolithiasis. Therefore, the incision of the left 1-3 hepatic duct is important for the treatment of hepatolithiasis and stenosis. (1) Left hepatic duct (first-stage hepatic duct) incision: the left hepatic duct is about 2 to 4 cm long, and the branches of the left branch of the portal vein mostly cross the front of the left hepatic duct. Generally, the incision of the common hepatic duct is performed, and the anterior wall of the left hepatic duct is cut longitudinally to the left, and basic techniques such as side slit, side sill, side cut, and side pull are adopted. Familiarity with and treatment of the left branch of the portal vein is extremely important for the left hepatic duct incision. One to three branches of the left side of the portal vein span the anterior wall of the left hepatic duct, and one of them accounts for 90%, and most of them span the end of the left hepatic duct. The left branch of the portal vein is <0.6 cm in diameter, and the middle hepatic artery is not included. The suture should be cut. If the diameter of the blood vessel is >0.6 cm, or accompanied by a middle hepatic artery, which is more common in patients with right hepatic atrophy and left hepatic compensatory hypertrophy, the method of retention is adopted without cutting. The method of retention is generally performed with double hepatic bile duct drainage, or an anastomosis of the bile duct basin. At this time, the left side branch of the portal vein should be kept 0.5cm across the outer bile duct to facilitate the anastomosis of the "hepatic bile duct" and the jejunum. In the following cases, the left hepatic duct incision should be used in the division method: 1 the primary hepatic duct is extensively densely adhered, scarred, the anatomical structure is unclear, the left hepatic duct tip is too small; 2 the left hepatic duct is tubularly narrow; the 3 portal vein is divided into the left side Branch diameter > 0.6cm; 4 portal veins span the anterior wall of the left hepatic duct; 5 left hepatic duct end severe, extensive scar or stenosis. The divisional method first cuts the common hepatic duct and the left inner or outer bile duct, and then extends the incision to the left hepatic duct and cuts the left hepatic duct. The approach of the teacher to enter the left hepatic duct is: 1 through the round ligament of the liver, cut the left inner lobe bile duct, access to the left hepatic duct; 2 through the left outer lobe to open the left outer lobe bile duct, access to the left hepatic duct; Through the left hepatic duct "stone feeling" obvious, directly cut the left hepatic duct; 4 through the left outer lobe resection, according to the left outer lobe or the left hepatic duct to the left hepatic duct. The left hepatic duct is incision, and the left hepatic triangle ligament and the left coronary ligament can be cut when needed, which helps the left hepatic duct to be revealed. Sometimes, in order to reveal, the liver lobe is removed. If the left hepatic duct is treated with a stone sensation, the left hepatic duct should be punctured and the vascular bypass should be determined. On both sides of the hepatic duct, a circular needle thread is threaded along the longitudinal axis of the left hepatic duct, and the whole layer is sutured and pulled. Then, a sharp knife is used to gently cut a small mouth between the two lines, and the cutting edge is sewn and pulled by a full layer of round needle thread. Follow the hepatic duct to extend the incision. (2) left inner lobe bile duct, left outer lobe bile duct and left caudal bile duct (secondary hepatic duct) incision: after left hepatic duct incision, left inferior bile duct mouth, left outer lobe bile duct mouth and left tail lobe bile duct mouth are exposed In the surgical field. The proximal end of the left inner bile duct and the left outer bile duct is outside the liver parenchyma. The left caudal bile duct is vertically downward, completely within the liver parenchyma. According to the preoperative examination, combined with the findings of the operation, combined with fiber choledochoscopy, comprehensive comprehensive analysis, it is not difficult to determine the location of the bile duct. These intraoperative pathological findings such as: 1 liver surface adhesions and fibrous scars, reflecting long-term repeated biliary tract infections cause localized liver fibrotic changes, therefore, these changes suggest hepatic bile duct stones and stenosis lesions. 2 regional cholestatic liver, such as the left outer leaf is dark green, indicating the presence of left outer biliary obstruction. 3 liver surface stone feeling, has important value for determining the location of the lesion. 4 hepatobiliary stenosis, suggesting that the lesion is in the bile duct. 5 thickening of the bile duct wall, stones or purulent bile, is the most powerful basis for determining hepatic bile duct lesions. According to the above determination of the lesion, the operation can be performed to the bile duct. The left caudal bile duct is generally a branch, and the direction of travel is vertical and backward. It is the most easy to handle in the secondary bile duct, but it is often ignored by the surgeon. In the treatment of left caudal bile duct lesions, in cases of stenosis and better elasticity, a moderate biliary dilator can be used, from small to large, light and continuous force expansion, when the left caudal bile duct is annular, true stenosis and left When the caudal lobe bile duct is obviously dilated, you can use appropriate forceps to probe into the left caudal bile duct, gently pick it up, look for the membranous part that is close to the left hepatic duct, and cut it in a v shape. Intermittent suture with a round needle thread. If the diamond-shaped wound of the caudal biliary ostium that has been cut is relatively wide, the autologous venous piece may be selected to cover the wound. The edge of the venous piece was fixed with a 5-0 non-invasive suture suture. The bile duct that has been cut or repaired should be placed with a hose or biliary balloon catheter for support, dilation, and massage to prevent restenosis of the bile duct. The left inner lobe bile duct approach, first cut the lower left bile duct, and access the left inner lobe bile duct. Sometimes, the bile duct is cut from the left liver surface or the sacral surface, and then the bile duct is gradually advanced to the left inner lobe. When the left second liver tube is exposed and cut, the basic techniques such as side seam, side ties, side traction, side cutting, puncture and guiding should be used flexibly. The left outer lobe bile duct approach, first cut the lower bile duct of the left outer lobe, reversely travel to the left outer lobe bile duct; or choose the "stone feeling" most obvious. In addition, if necessary, the hepatic segment resection approach is used, the lower left segment of the left outer segment is removed, and the left outer bile duct is exposed. Whether using the left extrahepatic bile duct approach, or the method of revealing the left outer lobe bile duct, the anterior bile duct liver tissue must be removed or cut. When the liver tissue section is hemorrhage, it is advisable to sew the liver and bile duct cutting edge with a round needle thread. (3) Incision of the upper left and lower bile ducts, the upper left inner lobe and the lower bile duct (left third grade hepatic duct): The third-grade hepatic duct is generally in the liver parenchyma, and the liver tissue covered by the outer layer is thick and thin, and there is no large branch of the portal vein, so it is safer and difficult to handle. The left inner lobe bile duct incision was made through the medial ligament of the liver, and the lower bile duct was cut in the left inner lobe. Or prolong the left inferior lobe 4 to 5 liver canal incision, through the medial ligament of the liver, cut the lower bile duct of the left inner lobe. Through the incision of the left outer leaf bile duct, the distal end is extended, and the lower bile duct of the left outer lobe is cut. Or extend the 4~5 grade hepatic duct incision in the left outer lobe, and cut the lower bile duct in the left outer lobe to the proximal end. The left third grade hepatic duct can also be directly cut through the obvious stone sensation; or the 4th to 5th grade hepatic duct can be seen through the left hepatic lobe or the outer lobes, reaching the third grade hepatic duct; or the cut is The left inner lobe or the left outer lobe bile duct and the stone were obvious, and the third grade liver tube was cut. (4) the right hepatic duct (first-stage hepatic duct) is cut; The right hepatic duct is generally 0.84 ± 0.56 cm long. To cut the right 1-3 grade liver tube, the gallbladder should be removed first, and the gallbladder bed should be used as the approach. After cholecystectomy, the right hepatic duct clearly appears outside the liver parenchyma. The fibrous connective tissue of the anterior wall of the hepatic duct was separated, and the hepatic duct was guided by a moderate forceps (cholecystectomy, right angle bending forceps, stone pliers, etc.), and the anterior wall of the right hepatic duct was incised. For example, the right hepatic orifice is only the size of the needle tip, and the scar adhesion is serious, but the stone is obvious. The right hepatic duct can be directly cut and the retrograde will be cut. The right hepatic duct is cut. In the case of intrahepatic hepatic hilum, the right hepatic duct is plunged into the liver parenchyma, and can be placed close to the right anterior wall of the common hepatic duct. The liver tissue is gently pushed open with "peanuts" to reveal the anterior wall of the right hepatic duct. The sutures of the common hepatic duct and the right hepatic duct should be pulled to the left and the lower side with a mosquito clamp to facilitate the incision of the right hepatic duct. (5) Incision of the right anterior bile duct and the right anterior lobe bile duct (right front 2 to 3 hepatic duct): The right front 2 to 3 liver tubes were all cut in the gallbladder bed. Use the index finger or appropriate forceps (cemental forceps, stone pliers, etc.) to penetrate into the right anterior bile duct and the right anterior lobe bile duct, and slightly pull and support the pelvic direction. Walk along the bile duct with empty needles, 0.3cm apart, puncture the anterior wall of the right anterior bile duct one by one, and find out if there is a branch of the hepatic vein. The branch of the middle hepatic vein spans the right anterior bile duct at the midline of the gallbladder bed. To cut off the middle hepatic vein, it is advisable to use a round needle thread as the blood vessel and the anterior wall of the bile duct to sew together. If a large blood vessel is found in the anterior wall of the right anterior bile duct, the liver color of the right anterior lobe becomes purple after 15 minutes of local test, indicating that the blood vessel cannot be ligated and cut. In patients who have not had a gallbladder resection in the past, the liver tissue outside the anterior wall of the right anterior bile duct is generally about 0.5 to 1 cm thick. If the cholecystectomy has been performed in the past, the thickness of the liver tissue and scar outside the anterior wall of the right anterior bile duct is about 1.5 cm. However, because it is scar tissue, there is usually not much bleeding. The liver tissue outside the anterior wall of the bile duct can be removed by clamping, incision, ligation or finger blunt compression to expose the right anterior bile duct and the anterior wall of the lower anterior bile duct, and then antegrade incision. Sometimes the round needle thread can be used to suture the anterior wall of the bile duct and the liver tissue outside the anterior wall of the bile duct. If the right anterior palpebral calculus is obvious, it can be cut before the part, the stone is taken, the bile duct is cut from the sacral surface to the dirty surface, and the lower anterior lobe of the right anterior lobe is cut; or the retrograde incisor cuts the lower anterior bile duct and the right anterior bile duct. If the stone is not obvious, it is difficult to cut the right anterior leaf bile duct through the gallbladder bed. The liver tissue in the lower right anterior lobe can be removed. The right anterior lobe bile duct is retrogradely cut through the gallbladder bed through the lower bile duct of the right anterior lobe of the liver section. (6) right posterior bile duct, right caudal bile duct (right posterior secondary hepatic duct) and right anterior lobe bile duct (right anterior third grade hepatic duct): when the right hepatic duct, the right anterior bile duct and the right anterior lower bile duct are incision, right The posterior bile duct, the right caudal bile duct, and the right anterior lobe bile duct opening are all in the posterior wall of the hepatic bile duct that has been cut. Carefully explore the above bile ducts, remove the stones, rinse with 2% hydrogen peroxide, and rinse with saline. If the bile duct is found to be narrow, the treatment methods are mainly expansion, shaping and repair. In order to facilitate the operation, the right triangle ligament and coronary ligament of the liver can be cut off, and 2 to 3 large gauze pads are placed under the arm to support the right liver, which is beneficial to the above-mentioned bile duct treatment. Dilatation of the bile duct: take the catheter, hemostatic forceps, biliary dilator, etc. from small to large, lightly and continuously expand the bile duct, and walk along the bile duct to prevent the injury from penetrating the bile duct wall to form a false path. This method can be used as a treatment when the bile duct is a mild membrane-like annular stenosis. However, when the bile duct is severely narrow, it can only be used as a preparation for bile duct formation. Bone tube formation: it is a common method for the treatment of the right posterior bile duct, the right caudal bile duct and the right anterior lobe. The formation methods include: right caudal bile duct and right posterior bile duct formation; right caudal bile duct and right hepatic duct formation; right anterior lobe bile duct and right anterior bile duct formation; right posterior bile duct and right anterior lobe bile duct formation. The method of forming is performed in a membranous portion adjacent to the wall of the bile duct, and a v-shaped incision is made, and the cutting edge should be sufficient to stop bleeding. The bile duct opening after bile duct formation should be slightly larger than the maximum diameter of the bile duct above the stenosis. It has a built-in biliary balloon catheter support. Repair of bile duct mouth: In order to prevent the resected bile duct mouth from being narrowed again, the autologous vein piece is used to repair the diamond-shaped wound formed by cutting the bile duct. It is often used for wound treatment of severe scar stenosis in the right posterior bile duct. The balloon catheter support should be placed after repair. (7) Incision of the upper right bile duct and the lower right lobe lower bile duct (right posterior third grade hepatic duct): Due to the right hepatic hypertrophy, deep in the armpit, it is difficult to reveal. However, the grade 3 hepatic duct stones in the right posterior lobe are less than the left side, and the current experience of surgery is still not much. 7. Establishing the hepatobiliary tube The bile duct of the hepatic bile duct is to divide the adjacent common hepatic duct and the adjacent edge of the 1-3 grade hepatic duct. The suture is sutured with 5-0 non-invasive suture, and the knot is made outside the bile duct, making it a The inner wall is smooth and the edges are neat, and there is no large hepatic bile duct with stenosis of the liver orifice of grade 1-3. Because it looks like a pot, it is called a hepatobiliary tube. The "hepatic bile duct" can be composed of a common hepatic duct and a grade 1 to 3 hepatic duct, which is located at the center of the liver and is called a central basin. It can also be composed of grade 2 to 3 hepatic ducts, located in the liver, called the partiality basin. A patient can establish a hepatobiliary tube, or there can be 2 to 3 hepatobiliary basins. Clinically, a single central basin is more common, and the establishment of eccentric basins is mostly due to the preservation of blood vessels that cross the hepatic duct. It should be noted that the tension should be avoided when the seam is adjacent to the edge of the hepatic bile duct; and the bile duct of the cut bile duct wall should not be sutured. The purpose of establishing a hepatic bile duct is to prevent the hepatic bile duct from being re-stenosis, to facilitate the discharge of residual stones, and the flow of bile. In principle, the hepatic bile duct should be placed on the liver surface to facilitate bile drainage. 8. Before the transection of the common bile duct, it should be determined whether the distal end of the common bile duct is unobstructed. For the transverse method, see biliary jejunum y-type anastomosis. 9. Preparation of interspersed or inactivated jejunum Interrupted position of the interposition or loss of function jejunum fistula: Lift the transverse colon, find the duodenal suspensory ligament at the root, pull out the jejunum, and discriminate the mesenteric vessels by light through the light at 15 to 30 cm from the beginning. The jejunum is placed into the hepatic bile duct, and the most loose part of the mesentery is selected to determine the position of the jejunum. Proper treatment of the mesenteric vascular arch, separation of the mesentery: in order to relax the interstitial or inferior jejunal mesentery, the method shown in Figure 3 is used as a mesenteric incision, and the serosal membrane on both sides of the mesentery on the pre-cut line is cut, clamped and cut. , ligation of mesenteric grade 2, grade 3 vascular arch. If the 2nd and 3rd grade vascular arches are short, the blood vessels can be sutured with a 4-0 round needle thread and then cut between the two ligatures. About the length of the interposition or loss of function jejunum: For example, the combined anti-reflux device with the artificial nipple placed in the jejunum is suitable for about 20cm, and the anti-reflux for the length of the intestine is preferably 60cm. If the incompetent intestinal fistula is placed in combination with the intussusception, the combined anti-reflux device is preferably 30cm. However, if the length of the intestine is anti-reflux, 60 cm should be taken. In addition, if the diameter of the hepatic bile duct is longer, the cut jejunum should also be longer. The arterial vessels of the interposition of the jejunum are preferably two. The serosa and soft tissues around the mesial should not be stripped at the time of cutting, and the mesangium should be relaxed, but not distorted. On the right side of the colonic mesenteric artery, there is no blood vessel puncture on the right side of the colon. The jejunal segment of the transverse collateral is punctured through the transverse mesenteric membrane to the mesorectum of the transverse colon, and then two straight Kirk forceps are used to poke the transverse mesenteric membrane. The jejunum was cut by clamping the upper and lower mesangial membranes respectively. Thus, the interposition or loss of function of the jejunum is naturally in the subhepatic space. Close the proximal or inferior jejunum fistula. Loss of function or interposition of the proximal jejunum to the marginal incision. Generally, the incision is 5 to 7 cm long. The proximal end of the incision should not be more than 2 cm from the proximal end of the intestine. When incision, the submucosal blood vessels should be sutured or clamped and ligated to stop bleeding. The end of the jejunum end-end anastomosis; or the original jejunal end and the dysfunctional jejunum side anastomosis. The edge of the transverse mesenteric puncture should be intermittently sutured and fixed on the intervening or inferior jejunum. The mesenteric margin should be interrupted and closed to avoid the formation of internal hemorrhoids. 10. Hepatobiliary tube and jejunum anastomosis Hepatobiliary tube and jejunum anastomosis, there are two ways of hepatic bile duct and interstitial jejunum or inferior collateral proximal incision anastomosis. The former is used as an example. Hepatic bile ducts with a diameter greater than 4 cm are often sutured continuously, and those less than 4 cm are often sutured intermittently. Double hepatic bile ducts are often anastomosed by an overpass. The right side of the hepatic bile duct is too long and can be used for " Gallbladder Bridge" or p-shaped bowel. (1) Single hepatic bile duct and an incision of the jejunum incision: the proximal vaginal incision is placed close to the hepatobiliary tube, and the traction line at the edge of the hepatic bile duct is pulled over the jejunal incision and pulled outward and downward. 1-0 round needle thread from the midpoint of the posterior margin of the incision and the midpoint of the posterior margin of the hepatic bile duct, for the intermittent valgus full layer suture, first to the left, to the left corner, the needle spacing is about 2.5mm; Cut off the traction line. After the left rear is stitched, the right rear corner is stitched to the lower right corner. The biliary balloon catheter was placed as needed, and the intestine segment was taken out 10 cm from the anastomosis. The double purse was sutured and the drainage tube was fastened. The same method was used to suture the incision of the intestine and the leading edge of the hepatic bile duct to complete the anastomosis Rinse the balloon catheter. If the anastomosis is leaky, the needle can be used to reinforce the needle. (2) double hepatic bile duct jejunum anastomosis: double hepatic bile duct jejunum anastomosis, also known as hepatic bile duct basin overpass anastomosis. The central canal located in the primary hepatic duct and the eccentric basin in the second to third grade hepatic duct were anastomosed to the two lateral incisions of the corresponding intervening or inferior jejunum proximal end. According to the method of single hepatic bile duct and interposition of jejunum incision, the posterior margin of the right or left hepatic bile duct between the two hepatic bile ducts was used as the central basin and the eccentric basin and the incision. After the anastomosis, place the biliary balloon catheter as needed. Then from the right or left side of the vascular bridge, the anterior border of the hepatic bile duct, the central basin and the eccentric basin coincide with the leading edge of the incision. Flush the biliary balloon catheter to observe the presence or absence of bile leakage, especially the anterior and posterior wall corners of the hepatic bile duct and jejunal anastomosis and the upper right corner of the hepatobiliary basin. (3) Hepatobiliary bile duct bridge jejunum anastomosis: the same method as the single hepatic bile duct and the interposition jejunal incision, the difference is mainly in the treatment of gallbladder. Full gallbladder bridge: use a complete, free gallbladder bridge. The method is to first open the posterior wall of the gallbladder body, suture it with the 3-0 gut and suture the right half of the hepatic bile duct, and then open and separate the anterior wall of the gallbladder body, fully hemostasis and anastomosis with the jejunum. Secondary total gallbladder bridge: subtotal resection of the gallbladder, leaving the posterior wall of the gallbladder for bridge. The method is directly in the posterior wall of the residual gallbladder, side slit, side ligature, side cut, side traction to cut the right hepatic duct, right anterior leaf bile duct and right anterior lobe bile duct, complete right hepatic duct and right anterior lobe grade 2~3 hepatic duct and residual The edge of the gallbladder fits into the jejunum incision. Gallbladder serosa bridge: When the gallbladder is removed under the serosa, the serosal membrane should be left as much as possible. The remaining margin of the gallbladder serosa is sutured with the right half of the hepatobiliary tube, and then the jejunal incision is sutured to the base of the gallbladder serosa. As a gallbladder bridge, biliary balloon catheter support should be placed inside. 11. Anti-reflux device intestinal reflux can cause reflux cholangitis, so anti-reflux device is an important measure. Clinically used anti-reflux devices are: (1) Artificial full-thickness nipple: 1cm of the ectaplasty of the distal jejunum at the distal end of the jejunum. The whole layer of the everted intestine and the jejunal musculocutaneous layer were sutured and fixed 12 to 16 needles by a single needle thread. Layer nipples. The artificial nipple formed by the entire mucosal valgus at the distal end of the jejunum is too large. It can be obliquely excised 1/2 of the circumference of the jejunum before eversion, and the entire margin is sutured. Then the mucosal valgus is sutured to the jejunosar muscle. On the layer, the artificial nipple formed after the eversion can be accommodated in a diameter of 1.5 cm. (2) Artificial mucosa nipple: the musculoskeletal layer of the distal jejunum is excised, the mucosa is valgus, and the valgus mucosa is sutured and fixed on the sarcolemma by a round needle thread, which is an artificial mucosa nipple. (3) squirming intussusception: two intestinal clamps were placed, 8 cm apart, perpendicular to the longitudinal axis of the intestine, and the jejunum intended for intussusception was completely clamped, and the two collateral muscles were placed at a distance of 1 cm from the edge of the two clamps. After suturing 12 stitches, suspend the intestine forceps and knot them one by one. (4) Synchronous suture: The proximal end of the intestinal anastomosis is sutured and sutured with the original intestinal tube as the sarcoplasmic layer, and the length is 6-10 cm. (5) prolonged interstitial or inoperable intestinal fistula: generally 50 to 80 cm, to prevent the intestinal contents from returning into the hepatic duct by the length of the intestine. Practice has proved that the combined anti-reflux device is better than a single one. The anti-reflux device of the liver and bile duct roux-y includes: 1 synchronous suture; 2 peristaltic intussusception. The anti-reflux device of the hepatic bile duct interposer includes: 1 artificial full-thickness nipple; 2 simultaneous suture. 12. The anastomosis of the jejunum and duodenum is selected to correspond to the duodenal papilla in the second segment of the duodenum. For the duodenal transverse incision: the second segment of the free duodenum, the transverse incision of the anterior duodenum corresponding to the duodenal papilla, the length of which is slightly shorter than the transverse diameter of the artificial nipple. The artificial nipple is anastomosed to the duodenum. Usually two layers of stitching. The first suture was sutured with a 1-0 round needle thread to suture the upper edge of the duodenal incision, the artificial full-thickness nipple posterior wall valgus jejunum margin, and the interposition of the jejunal muscle layer a total of 8 to 12 needles, one by one Knotted, complete the upper edge of the duodenum and the posterior wall of the artificial full-thickness nipple. The lower edge of the duodenal incision was anastomosed with the anterior wall of the artificial full-thickness nipple. The second layer was sutured to the duodenum of the first layer of the anastomosis with a width of about 0.5 cm and the jejunal muscle layer was sutured intermittently, and the first layer of anastomosis was embedded, and a artificial sphincter capsule was formed to enhance the anti-reflux effect. When sewing the first layer, be careful not to damage the nipple mucosa. The medial horn of the nipple and the duodenal incision are prone to convulsions. Care should be taken. After the nipple duodenal anastomosis is completed, the duodenum is returned to the original anatomical position. 13. Place a hose or cigarette drainage in the hypohepatic space, together with the balloon catheter placed at the anastomosis of the gallbladder, and poke out from the right upper abdominal wall. 14. Layered suture of the abdominal wall incision.