Congenital Choledochal Cyst Surgery

Congenital choledochal cyst surgery has many methods, which can be divided into the following three types: 1. Cyst resection due to complicated operation, large trauma, easy to damage the pancreatic duct system, high mortality, and rarely used. In recent years, due to the development of biliary surgery and the high rate of malignant cysts, cystectomy has received increasing attention. 2. External drainage of the cyst is a temporary operation, due to the heavier condition, can not tolerate more complicated internal drainage surgery. After the condition is stable, the general condition is improved, and the second stage cystectomy is performed. 3. Internal drainage of cysts includes cystic and gastric anastomosis, cyst duodenal anastomosis, cystic jejunostomy and y-shaped surgery. Cyst duodenal anastomosis is relatively simple, but it is easy to cause retrograde infection of the biliary tract. There are fewer chances of retrograde infection in y-shaped surgery, but the surgery is more complicated. The surgeon can choose according to the condition. Treatment of diseases: choledochal cyst Indication All patients with congenital choledochal cysts who have symptoms should be treated surgically. If the patient is generally in good condition, there is no obvious infection, and the adhesion between the wall and the surrounding area is not heavy. In particular, the biliary tract angiography has pancreaticobiliary malformation and pancreatic juice reflux, which may form intrahepatic and extraluminal bile duct dilatation. It should be used as a common bile duct cyst. cut. Preoperative preparation 1. Control infection, correct malnutrition and imbalance of water and electrolyte balance. Sufficient vitamins should be given, and antibiotics, infusions, blood transfusions should be used reasonably to improve the general condition. 2. Pay attention to check for jaundice, liver function changes and coagulation function. Should give liver protection drugs, large doses of vitamin K and appropriate amount of blood coagulation drugs. Surgical procedure (a) congenital choledochal cystectomy Long-term clinical practice has proven that the drainage of the common bile duct cyst is not effective. In addition to a high retrograde infection rate and stone formation, the cystic malignancy rate was 2%, the total morbidity rate was as high as 60%, and the reoperation rate was 40%. Therefore, cystectomy has received increasing attention. The advantages are: 1 complete removal of the lesion, eliminating the source of bile retention, infection and stone formation. 2 obviously can prevent the malignant changes of the lesion. 3 significantly reduced the rate of morbidity and reoperation rate. 1. Position: supine position, the right side is raised. 2. Incision: right upper transabdominal rectus incision, or right upper median incision or right inferior inferior incision. 3. Exploring: Defining the scope of biliary dilation. If the cyst is too large and the boundary is unclear, the cyst in the capsule can be aspirated and then probed. When it is clear that the extrahepatic bile duct is a cystic dilatation type, and the adhesion to the surrounding is not heavy, it is feasible to perform cystectomy and biliary reconstruction. 4. Exposure of the cyst: First, the colonic hepatic vein is separated to reveal the descending part of the duodenum. The peritoneum was removed from the lateral side of the descending artery to reveal the lower end of the cyst. The peritoneum of the hepatoduo duodenal ligament was incised parallel to the upper edge of the pancreaticoduodenal, the funnel of the lower end of the cyst was exposed, and the adhesion to the surrounding was separated. After the funnel was ligated, the lower end of the common bile duct was cut. The distal stump was closed with a 1st wire interrupted or continuous suture. The lower end of the cyst was pulled and the adhesion to the hepatic artery and portal vein on the left side was carefully dissected. Continue to separate the cyst from the posterior wall to the level of the cystic duct, close the gallbladder neck and cut the gallbladder artery, and cut the gallbladder from the gallbladder bed. Continue to dissect the hepatic portal and reach the junction of the left and right hepatic ducts. If the cystic inflammatory adhesion is severe, the left and posterior walls are closely adhered to the pancreas, portal vein and hepatic artery. Intracapsular resection can be used to preserve the outer wall of the cyst and the outer wall of the left wall for safety. That is, the traction line is first sewed in the anterior wall of the cyst, and the physiological saline containing epinephrine is injected on the tangential line to reach the submucosal wall of the cyst wall, so that the bleeding is reduced and the separation is easy. Then, the front side of the capsule wall is cut transversely, and the posterior wall and the left side wall are retained to avoid damage to important blood vessels and the like. 5. Preparation of roux-y jejunal fistula: According to the distribution of jejunum vascular arch, the jejunum and mesangium were cut off from the duodenal suspensory ligament 10-15 cm. The suture was continuously sutured with a 1-0 silk thread to close the proximal end of the distal jejunum. A hole is cut in the right avascular region of the transverse mesenteric membrane, and the distal jejunum is sent through the hole to the hepatic portal. The main hepatic duct was cut at 1 to 2 cm below the junction of the left and right hepatic ducts. 6. Bile duct intestinal anastomosis and intestinal reconstruction roux-y reconstruction of the bile duct and the intestinal tract in the first line of jejunal common hepatic anastomosis. The jejunum was cut at the lateral edge of the mesentery 3 to 4 cm from the closed end of the slit. The incision is slightly larger than the diameter of the common hepatic duct to avoid stenosis after anastomosis. After the whole layer of the posterior wall was sutured intermittently with a 1-0 silk thread, the entire anterior wall was sutured to complete the jejunal bile duct anastomosis. Finally, the proximal jejunal end and the distal jejunum end anastomosis were performed about 50 cm below the jejunal bile duct anastomosis to complete the y-type digestive tract reconstruction. Intervening jejunal bile duct duodenal anastomosis This procedure has the advantages of avoiding reflux cholangitis, maintaining normal duodenal gallbladder and pancreatic digestive function, and reducing the incidence of roux-y anastomosis. The incidence of ulcer disease. The operation of jejunal bile duct anastomosis is the same as the roux-y procedure. The jejunum was cut at 20 to 30 cm below the biliary anastomosis, and the mesenteric blood supply of the intestine was retained. The length of the intestine is usually about 20 cm for children and about 30 cm for adults. In the second part of the duodenum, the third outer wall was cut open, and the jejunum and duodenum full-thickness intestinal wall were sutured intermittently with a 1-0 silk thread, and sutured and reinforced by the sarcoplasmic layer. Finally, the proximal and distal jejunal end points left after the jejunum was placed in the anastomosis to restore the smoothness of the intestine. (B) congenital choledochal cyst duodenal anastomosis 1. Position: supine position, the right side is raised. 2. Incision: upper transabdominal rectus incision. 3. Exposure of the gallbladder: After entering the abdominal cavity, pull the liver upwards, you can see the enlarged common bile duct, the duodenal bulb below it, the deep green bile can be obtained by puncture, and the bile should be exhausted as much as possible; Or cut a small mouth, the bile is sucked out for easy matching. 4. Cyst duodenal anastomosis: in the lowest position of the cystic dilatation of the common bile duct and the first part of the duodenum to be anastomosed, the two muscle pulp layers are sutured continuously and sutured by suture. The cyst and the duodenal wall were cut parallel to the suture, and the size of the incision should not be less than 5 cm. The inner layer of the posterior wall of the anastomosis is sutured with a thin wire as a seam or a discontinuity. The inner layer of the anterior wall of the anastomosis was sutured by a full-thickness varus suture. The outer layer of the anterior wall of the anastomosis was sutured by intermittent varus suture of the pulp muscle layer. 5. Stitching: After the anastomosis, the anastomosis should be able to pass the two fingers. A cigarette is drained at the hole of the omentum, and the outside of the incision is additionally poked out of the body, and the abdominal wall is sutured layer by layer. (three) congenital choledochal cyst jejunostomy (y-shaped anastomosis) 1. Observe the choledochal cyst and the first part of the duodenum as described above. 2. Cut the jejunum and its mesangium 15 cm below the duodenal suspensory ligament. The distal end of the jejunum is lifted from the transverse colon and is close to and coincides with the bottom of the cyst. The anastomosis is not less than 4 to 5 cm. 3. The proximal end of the jejunum is then anastomosed to the distal jejunum. The two anastomosis are at least 30 cm apart. 4. Close the transverse mesenteric and jejunal mesangial pores.