Intervening jejunal bile duct duodenal anastomosis

Intermittent jejunal duodenal anastomosis refers to the anastomosis of a metacarpal jejunum between the bile duct and the duodenum. The advantages of this procedure are: 1 bile still flows into the duodenum, in line with bile flow physiology; 2 anastomotic large, local tension-free; 3 avoid postoperative peptic ulcer may be induced; 4 add anti-intestine on the interposition of jejunum A biliary reflux device, or an extended interposition of the jejunum, prevents intestinal reflux. Treatment of diseases: gallstones, cholelithiasis Indication 1. Common bile duct, common hepatic duct, or left and right hepatic duct inflammation and obstruction. 2. Intrahepatic bile duct stones, chronic recurrent suppurative cholangitis, the main intrahepatic calculi have been cleared, but there are still stones in the bile duct above the secondary branch. 3. Recurrent bile duct stones, and the bile duct is obviously enlarged. 4. Chronic recurrent suppurative cholangitis, a significant enlargement of the bile duct. 5. Reconstruction of biliary intestine drainage after biliary tumor resection. 6. If the bile duct injury is broken or the scar is narrow after the trauma, the bile flow is interrupted and blocked. 7. A small number of congenital extrahepatic biliary strictures or atresia. Contraindications There are serious obstacles to the coagulation mechanism. High blood pressure, diabetes, and some bleeding-prone diseases. Preoperative preparation 1. The patient's general condition is poor, and liver function is often damaged and needs to be corrected. 2. There are biliary tract infections, or more history of repeated biliary tract infections, even if there are no clinical symptoms, hidden infections often exist, antibiotics should be applied before surgery. 3. A small number of long-term biliary drainage, often water and electrolyte imbalance, should be properly corrected before surgery. 4. If the jaundice is serious, it is advisable to first make ptcd, wait until the jaundice is relieved, and the liver function is improved before surgery. 5. Need to pay attention to the correction of coagulation mechanism disorders. 6. Patients with intestinal ascariasis should be dewormed before surgery. 7. Prepare the upper digestive tract, 2g of neomycin 24 hours before surgery, orally every 6 hours. 8. In the morning, the gastrointestinal decompression tube. Surgical procedure 1. Position: supine position, the liver gate area is aligned with the lumbar bridge of the operating table. 2. Incision: The right upper abdomen is incision through the rectus abdominis or the right upper midline. 3. Exploration and exposure: enter the abdominal cavity, first explore, determine the hepatobiliary lesions, decided to take the surgical procedure, reveal the hilar bile duct area. 4. Incision of the common bile duct, treatment of biliary tract lesions: the same bile duct jejunum roux-y anastomosis. 5. Excision of the gallbladder: removal of the gallbladder to avoid secondary cholecystitis. 6. Treatment of biliary tract lesions: see bile duct jejunum roux-y anastomosis. 7. Cut the common bile duct or common hepatic duct, and the distal suture is closed. After the biliary tract lesion is treated, the common bile duct or common hepatic duct is cut off. Should be separated, cut off, suture the bleeding point to stop bleeding. Be careful not to damage the portal vein in the back. After transection of the bile duct, the distal end was sutured and the proximal end was corrected, resulting in a large enough bile duct to be anastomosed to the jejunum (see bile duct jejunum roux-y anastomosis). 8. Cut the jejunum with pedicle and perform anastomosis of the gallbladder: cut the jejunum about 20 cm below the duodenal suspensory ligament. The proximal segment was sutured to close the free intestine, and the pedicle jejunum was closed by a double-needle method. The method is as follows: 1 firstly perform continuous full-thickness inversion on the tongs; 2 gradually tighten the suture, and gradually remove the tongs, at which time the intestinal wall has been completely inverted; 3 the original suture is from the sides to the center For continuous pulpis varus suture; 4 knotted at the center. After the proximal end suture was closed, the four silver clips were clamped for later positioning under the x-ray and placed under the skin for subcutaneous blind sputum. 10 to 15 cm from the upper end of the closed end and the bile duct to do the posterior side of the colon, the first anastomosis, the wire is intermittently valgus single-layer suture. If the blind intervening procedure is not performed, the bile duct jejunal end-to-side anastomosis is performed 4 to 5 cm from the blind end, and then the jejunum is cut off 60 cm from the anastomosis. Note that this free jejunum segment needs to retain 1 to 2 supply arteries to maintain the supply of blood circulation. The mesentery should not be strained. In cases where the mesentery is short, it must be properly cut. The mesentery with tension, although retaining two arteries in form, is not as effective as cutting an artery to loosen the entire mesangium. A one-way vascular bow without tension, it is easy to keep blood flowing smoothly. 9. Closed and distal jejunal end-to-end anastomosis: the proximal part of the jejunum and the distal part of the jejunum are intermittently sutured with silk thread, the inner layer is sutured in full layer, and the outer layer is sutured in the sarcoplasmic layer. This is the second anastomosis. 10. End-to-side anastomosis of the jejunum duodenum: the duodenal lateral peritoneum was dissected, and the duodenum was dissected from the back for easy anastomosis. The anterior side wall of the duodenum was cut longitudinally at the midpoint of the duodenal descending portion, and the incision was similar to that of the jejunum. After the incision, the contents of the intestine were aspirated and matched with the lower end of the free segment of the jejunum. The inner layer of the anastomosis was sutured with a full-thickness inversion of the suture, and the outer layer was sutured with the intermuscular muscle layer of the suture, which is the third anastomosis. The advantages of taking the above steps are as follows: 1 to ensure that the jejunum is squirming, because this step will not make a mistake, and the intervening jejunum will be mismatched, resulting in a serious retrograde infection. 2 If the patient's condition is not good after the completion of the first anastomosis, the distant jejunum can no longer be cut off, and the proximal jejunal end of the jejunum is anastomosed with the jejunum at 60 cm from the anastomosis. The general roux-y technique is completed and the operation is terminated for safety. 11. Closed mesangial hiatus: including jejunum and jejunum mesenteric hiatus, jejunum and transverse colon mesenteric hiatus, must be sutured closed to prevent internal hemorrhoids. 12. Place the subcutaneous blind sputum: It is not appropriate to place the closed end of the blind scorpion directly under the skin. Because the incision infection rate of the biliary tract reoperation is high, once the wound is infected, the closed end will be directly immersed in the pus, resulting in poor healing and blindness. Hey. Therefore, the closed end of the blind scorpion should be placed in the abdominal cavity, and the intestinal wall on the opposite side of the mesentery should be placed under the skin. Thus, even if the incision is infected, blindness does not occur. 1 proximal jejunum blind 2 first anastomosis (intermediately separated from the blind end 4 ~ 5cm, blind sputum between the blind end 10 ~ 15cm) 3 third anastomosis from the biliary anastomosis 50cm4 second anastomosis from the ten Two-finger suspensory ligament 20cm. The location of the blind sputum placed in the abdominal wall should be determined according to the distribution of intrahepatic stones. The blind fistula of the right hepatic bile duct stone should be placed in the incision, and the blind fistula of the left hepatic duct stone should be placed under the right costal margin. In this way, when it is necessary to take the stone from the blind scorpion in the future, the stone tongs or the choledochoscope are easy to enter the diseased side bile duct. complication Biliary obstruction: bile duct obstruction refers to any part of the bile duct obstruction due to bile duct lesions, tube wall disease, infiltration and compression outside the tube wall, causing bile duct mechanical obstruction due to poor bile excretion or even complete blockage.