Duodenal papilla sphincteroplasty (transduodenal)

The purpose of duodenal papillary sphincter angioplasty is to resolve the bile flow disorder caused by stenosis or obstruction of the lower common bile duct. The surgical method is to cut all the fibers of the biliary sphincter, and cut a part of the wedge, and then suture the duodenal mucosa. It is an operation to enlarge the lower end of the common bile duct and communicate the common bile duct and the duodenum. Treatment of diseases: chronic pancreatitis in children with chronic pancreatitis Indication 1. Incarcerated ampullary stones, especially mud-like stones. 2. The ampulla of the ampulla is scarred and hyperplasia. 3. Chronic recurrent pancreatitis, with Oedo sphincter spasm or stenosis, in the sphincter angioplasty, the lower end of the common bile duct. Contraindications 1. Secondary choledocholithiasis, bile clear, only a few large stones, nipple diameter greater than 3mm, choledochoscopy showed no abnormalities in the biliary tract, or normal cholangiography. 2. The lower end of the common bile duct is tubular and narrow, and the length exceeds the inner segment of the common bile duct of the common bile duct. 3. The abnormality of the proximal end of the bile duct (such as hepatic stenosis). 4. There are people who have a ventral ventral diverticulum. 5. Biliary inflammatory diseases including the pancreatic duct. Preoperative preparation 1. Emergency surgery: All patients must be preoperatively prepared for 6 to 24 hours to improve the general condition and tolerate surgical treatment. (1) fasting, intestinal paralysis, bloating, gastrointestinal decompression. (2) Intravenous infusion to correct water, electrolyte and acid and alkali balance disorders, if necessary, blood transfusion or plasma. (3) Appropriate application of broad-spectrum antibiotics. (4) Astragalus patients are injected with vitamins b1, c, and k, and those with bleeding tendency are intravenously injected with hexaamino own acid and p-carboxybenzylamine. (5) When there is toxic shock, shock should be actively rescued. 2. Selective surgery When the patient has long-term jaundice, dehydration, liver and kidney function damage, in general, when the situation is poor, the patient should be actively corrected before surgery, improve nutritional status, the application of high sugar, high vitamins and other liver protection treatment. 3. The surgeon should carefully understand the medical history, physical examination, laboratory tests and various auxiliary examination data, and have sufficient analysis and estimation of the condition. 4. Patients with stones should review b-ultrasound on the morning before surgery to observe the movement of stones, in order to prevent stones from draining the biliary tract and perform surgery. Surgical procedure 1. Position: supine position. 2. Incision: right upper transabdominal rectus or median side incision. 3. Explore the common bile duct: separate the adhesion, reveal the common bile duct, and cut the common bile duct longitudinally about 1.5cm under the two-needle filament of the anterior wall. Then, the lower end of the common bile duct was dilated with a small biliary dilator to enter the duodenum through the ampulla as a sign of the incision of the intestinal wall. 4. Incision of the duodenum: the peritoneum was cut along the lateral edge of the descending part of the duodenum to separate the descending part of the duodenum. Immediately with the finger on the anterior wall of the membrane biliary dilator head, in this area longitudinal or transverse incision about 2 ~ 3cm, with a suction device to suck the duodenal juice, ligation of bleeding points. 5. Exposing the duodenal papilla: Two tissue clamps were used to clamp and pull the bilateral intestinal wall of the duodenal incision, and the two saline gauze were respectively blocked in the upper and lower ends of the duodenal cavity. Find the duodenal nipple by finding the head of the biliary dilator. 6. Sphincter formation: Place the biliary dilator at the sphincter nipple as a guide. The anterior and lateral sides of the sphincter and the ampulla are equivalent to 10 o'clock. The scalpel or small scissors are used for wedge resection. The length of the incision is generally 1.5 to 2.0 cm, and the width of the bottom is 0.3 to 0.5 cm. Be careful not to make a wedge cut on the anterior medial or medial side to prevent damage to the pancreatic duct. Because the incision is long, it is easy to cause bleeding, and the bleeding point should be carefully sewed. Then, the sphincter incision was sutured with a 4-0 chrome gut for full-thickness suture, and the duodenal mucosa was combined with the mucosa of the lower end of the common bile duct. 7. Suture duodenal incision: Incision of the duodenum, short can be sutured horizontally, long should be sutured along the longitudinal axis of the duodenum to avoid angle and tension. The inner layer is sutured in a full-thickness with a silk thread, and the knot is wound in the intestine cavity to make the intestine wall invert; the outer layer is sutured with a thin silk thread for intermittent muscle suture. 8. Place the drainage tube and suture the abdominal wall: a t-shaped tube (or a long-walled t-shaped tube) is placed in the common bile duct, the lower end is passed through the sphincter, the upper end is placed in the common hepatic duct, and the common bile duct incision and peritoneum are sutured intermittently. Cigarette drainage was placed near the suture of the duodenum, and a small incision was made from the right abdominal wall along the tibial tube along the liver. Cigarette drainage is fixed with a safety pin. The t-tube is fixed on the skin with sutures. Finally, the abdominal wall incision is sutured. complication Wound infection.