Internal jugular vein transplantation, superior mesenteric vein and inferior vena cava H-shaped shunt

Internal jugular vein graft and superior mesenteric vein inferior vena cava H-shaped shunt for surgical treatment of portal hypertension. Portal hypertension is the result of impeded blood flow to the portal system. The main clinical manifestations are congestive splenomegaly, hypersplenism, gastric fundus and esophageal varices, and a large amount of hematemesis after varicose vein rupture, which can be life-threatening. It can also cause ascites. Superior mesenteric vein inferior vena cava shunt: divided into lateral shunt and end-to-side shunt. End-to-side shunt can be used to make anastomosis between the venous end of the vena cava and the superior mesenteric vein and the end of the superior mesenteric vein and the inferior vena cava. Match. Or take the autologous jugular vein bridge for "H"-shaped intestinal vena cava anastomosis. Curing disease: Indication Internal jugular vein graft and superior mesenteric vein inferior vena cava H-shaped shunt are applicable to: 1. Extrahepatic portal hypertension, esophageal varices rupture of upper gastrointestinal bleeding, no ascites, Hb100g / L or more. 2. Have done interrupted or shunt surgery, such as spleno-renal venous shunt and other effects are not ideal, repeated upper gastrointestinal bleeding again, consider this method of secondary shunt surgery. Contraindications Patients who have undergone lateral diversion or end-to-side shunting should not take this procedure. A small number of children with congenital internal jugular vein dilatation should not be taken because of poor vascular conditions. H-type shunt grafts should not be artificial. Blood vessels. Preoperative preparation 1. Patients with poor liver function should strengthen liver protection measures before surgery, including high protein, high calorie, high vitamin and low salt diet. 2. When the plasma protein is low, blood transfusion, plasma and albumin may be administered in small amounts. 3. Intestinal preparation 3 days before surgery, oral administration of neomycin, metronidazole, reducing the number of intestinal bacteria. 4. Preoperative B-ultrasound and other renal function tests to understand the functional status of the kidneys. Surgical procedure 1. First make an abdominal incision. The abdominal incision can be selected as a transverse incision in the upper abdomen or a median longitudinal incision through the white line. When the condition of the child is poor, the longitudinal incision is more likely to be split than the transverse incision due to the large injury. After laparotomy, the transverse colon is pulled upward, and the peritoneum is cut at the root of the transverse mesenteric membrane. Because of portal vein system congestion and edema due to portal hypertension, there may be lymphatic vessels in the peritoneal and extraperitoneal fat tissue after incision, which should be ligated or sewn one by one. Tie, in order to prevent postoperative chylothorax ascites. Carefully dissected the superior mesenteric and inferior vena cava, these steps are the same as the superior mesenteric vein-inferior vena cava lateral shunt. 2. Shorten the distance between the inferior vena cava and the superior mesenteric vein, and suture the fibers and adipose tissue adjacent to the two vessels with 2-0 silk sutures to close the two vessels. The method is the same as the superior mesenteric vein-inferior vena cava lateral shunt. After completing this step, if the two blood vessels have anastomosis conditions, the abdominal surgery is temporarily terminated, and the abdominal incision and the abdominal internal organs are properly protected by a sterile gauze pad. 3. Internal jugular vein resection The neck, chest and abdomen have been disinfected together before the abdominal operation, and the neck over-extension position and the shoulder pad are well-positioned with the thyroidectomy. (1) Incision: The right internal jugular vein is generally taken, and the incision takes a 2 cm transverse incision on the collarbone. (2) After incision of the skin and platysma, the upper and lower free flaps are each 3 to 4 cm. (3) Cut off one part of the right sternocleidomastoid muscle, and cut off the scapular lingual muscle. The two broken ends are marked with a needle of each thread. (4) Incision of the internal jugular vein: After the sternocleidomastoid muscle is incised, the carotid sheath can be revealed. At this time, the intracranial internal jugular vein is shaken with the breathing movement. Carefully open the carotid sheath. The intrinsic sheath of the internal jugular vein was incised, and the small branches that were not fixed were carefully ligated and the intrathecal was peeled off. At this time, the internal jugular vein, the vagus nerve and the common carotid artery were simultaneously exposed. Properly protect the internal jugular vein, vagus nerve and common carotid artery. The stripper was peeled tightly against the internal jugular vein wall for one week, and then the internal jugular vein was separated upwards and downwards. The free length was about 5 cm. The upper and lower ends of the vein were clamped without a damaged vascular clamp, and the internal jugular vein was removed 4 cm, and the upper and lower ends were 5 -0 Prolene continuous suture, fully hemostasis, cut the internal jugular vein to protect, suture the carotid sheath, suture the sternocleidomastoid muscle, platysma and skin in situ. 4. Internal jugular vein graft, superior mesenteric vein-inferior vena cava H-type shunt surgery, remove the dressing in the abdominal incision, re-expose the inferior vena cava and superior mesenteric vein, at the proximal end of the superior mesenteric vein (intersection with the splenic vein) 1/3 at the lower side with a non-traumatic auricular clamp clamped 2/3 of the side wall, and clamped the 1/2 of the inferior vena cava at the same level, first cut the inferior vena cava wall with a sharp blade 1 cm, and then cut the superior mesenteric vein 1cm, the proximal end of the internal jugular vein and the posterior wall of the inferior vena cava were sutured continuously for half a week with a 6-0 Prolene line. The anterior wall was sutured intermittently with 6-0 Prolene, and the vessel was washed with 1:100 heparin solution during suturing. The same method is used to continuously suture the distal end of the internal jugular vein and the posterior wall of the superior mesenteric vein. The anterior wall is interrupted and valgus suture. After the anastomosis is completed, the inferior vena cava side clamp is relaxed, and then the superior mesenteric vein side clamp is clamped. Relax, if there is oozing blood, you can repair 1~2 needles, then use warm saline gauze to stop bleeding, if necessary, spray with bio-protein glue at the anastomosis, and finally suture the peritoneum after cutting. 5. Incision suture layer by layer, the method is the same as the superior mesenteric vein-inferior vena cava end-to-side anastomosis. complication 1. Intrahepatic portal hypertension, divergence often occurs in different degrees of liver function decline, severe jaundice, ascites or even hepatic coma, especially after portal shunt, the mortality rate is higher. 2. Patients with poor liver function, active liver protection treatment.