choledochotomy

The main purpose of the common bile duct exploration is to explore the lesions of the biliary tract; remove the stones, aphids, blood clots, etc. in the biliary tract; drain the common bile duct to resolve the obstruction and infection of the biliary tract. Commonly performed clinically is the common bile duct incision above the duodenum. According to the condition, often concurrent cholecystectomy and cholangioenterostomy. Treatment of diseases: cholangitis bile duct stones Indication 1. Acute suppurative obstructive cholangitis. 2. Biliary tract infection complicated with liver abscess, biliary bleeding or toxic shock. 3. The patient has repeated biliary colic, jaundice, high fever or complicated pancreatitis. 4. Obstructive jaundice and cholangitis. 5. Cholangiography shows that the common bile duct has larger stones. 6. Surgical resection or resection of severe hepatic trauma, and extrahepatic bile duct repair or anastomosis should be performed with common bile duct incision and drainage. 7. In the cholecystectomy, the common bile duct exploration should be performed in the following cases: (1) There are multiple small stones in the gallbladder. The cystic duct is thick and short. It is estimated that stones may be discharged into the common bile duct. (2) The common bile duct is obviously thickened, hypertrophic, and has inflammation. (3) The common bile duct touches stones, mites or blood clots. (4) There are repeated episodes of jaundice. (5) The head of the pancreas is swollen or hard. (6) Puncture of the common bile duct to find bile, blood or pus in the bile. (7) intraoperative cholangiography showed that there were stones and mites in the liver and common bile 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 patients with 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, when the general condition is bad, the patient should actively correct before surgery, improve nutritional status, and apply high blood sugar, high vitamin 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, the upper abdomen is aligned with the lumbar bridge of the operating table. When the biliary tract is not well exposed during the operation, the bridge can be shaken. Place a cushion under the knee to relax the abdominal muscles. 2. Incision: usually the right upper abdomen through the rectus abdominis incision, or the right upper right side of the incision. 3. Exploration: same as cholecystectomy. 4. Expose the common bile duct: the first deep hook is placed on the left liver of the gallbladder, and a small gauze is placed under the hook to pull the liver leaf upward. The stomach, duodenum and transverse stones are separated by a saline gauze pad. The second deep hook pulls the stomach to the left to prevent the antrum from entering the surgical field. The third deep hook pulls the transverse colon and the duodenal bulb down, keeping the hepatoduodenal ligament straight and tight. A saline gauze is then filled into the retina hole to prevent bile or blood from flowing into the small retina cavity. The hook should have sufficient depth and the tension should be durable and uniform so that the above organs are not allowed to enter the surgical field during the whole operation. 5. Incision of the common bile duct: the right peritoneum of the duodenal ligament is incision, and the small gauze ball is clamped with a hemostatic forceps, and the peritoneum is carefully separated to make the bile duct of the duodenal ligament segment clear. Small blood vessels are often traversed in the anterior wall of the common bile duct, and thin filaments are used to prevent bleeding. At the proposed common bile duct incision (generally between the upper edge of the duodenum and the cystic duct into the common bile duct), a needle thread is sewed on both sides of the anterior wall of the common bile duct with a thin wire to test between the two traction lines. puncture. If bile is withdrawn, it is confirmed to be the common bile duct (bile culture, and drug sensitivity determination); otherwise, the location of the common bile duct should be determined again. After obstructive jaundice, the color of the bile is similar to that of blood after a long time; when the biliary tract is bleeding, blood is also mixed in the bile, and the appearance is difficult to identify. A small amount of the extracted contents can be injected on the white gauze, and if it is bile, it is yellow and has mucus. When the common bile duct can clearly clear the stones, this step can be omitted, and the common bile duct is cut directly on the stone. After the bile is obtained, the pressure measurement in the biliary tract can be performed if necessary. If there are conditions and needs, cholangiography can be performed. Then, lift the two sides of the traction line, and make a 1.5-2 cm long incision with a sharp-edged knife along the longitudinal axis of the common bile duct at the middle of the traction line. First penetrate perpendicular to the common bile duct wall, but not too deep, so as not to puncture the posterior wall of the common bile duct or injure the portal vein, and then enlarge the incision upwards and downwards. At the same time, the assistant uses the aspirator to absorb the bile flowing out. 6. Exploring the common bile duct: After the common bile duct is incision, pay attention to the diameter of the common bile duct, the thickness and hardness of the wall. If you have gallstones, use a stone cutter or a blunt blade to remove it carefully. Try to avoid crushing. If the common bile duct incision is not large enough, it should be properly enlarged before taking the stone; if it is a mud-like stone, it can be taken with a gallstone spoon; when there is a mites, it can be taken out with a clamp. The stone at the lower end of the common bile duct is pushed up as far as possible to the incision of the common bile duct. If you can't push it up, you can use the left hand to guide it and put it into the stone cutter or the gallstone to remove it. After the stones in the common bile duct are removed, the common hepatic duct and the left and right hepatic ducts are explored. Pay attention to whether they are narrow or not, and try to remove the stones or mites in the left and right hepatic ducts. If there are multiple stones in the left and right hepatic ducts, it is difficult to remove them. The common bile duct incision can be extended upwards to the left and right hepatic duct openings, so that the intrahepatic bile duct stones in the higher position can be taken out. For more complicated surgical treatment of intrahepatic bile duct stones, see intrahepatic biliary surgery. If there is a large amount of sediment-like stones in the hepatic duct, if the difficulty is difficult to take, the catheter can be placed into the left and right hepatic ducts, and the saline is repeatedly flushed with physiological saline to absorb the biliary saline flowing out. After the reflux liquid is basically clarified, the catheter is passed through the ampulla, and the test is carried out into the duodenum and washed with physiological saline; if there is no reflux, the lower end of the common bile duct is unobstructed; if there is reflux, it indicates that there is still obstruction at the lower end of the common bile duct. [Fig. 1 (8)]. If the common bile duct is very thick, the finger can be probed into the lower part of the common bile duct and the left and right hepatic ducts, and the residual stones, stenosis or tumor lesions can be carefully explored. 7. Dilatation of the lower end of the common bile duct: When the lower end of the suspected common bile duct is stenotic or obstructed, it needs to be dilated with a biliary dilator. The dilator should be slightly curved to accommodate the curvature of the lower segment of the bile duct. Usually use a small dilator, from the inside of the common bile duct to the equivalent of the sphincter, gently and properly press forward, while using the other hand on the anterior wall of the duodenum, to determine whether the end of the dilator enters twelve Refers to the intestines. When entering the duodenum through the sphincter, there is a sudden loss of resistance, and the dilator can rotate freely in the intestine. Then, replace the large dilator in sequence to expand until it reaches the 10th probe (1cm diameter). However, in the case of scarring stenosis of the sphincter, it is not violently expanded during expansion, resulting in complications such as injury or perforation. The lower end of the common bile duct outlet is too thin, should be considered surgical correction, sphincter incision. Sometimes, when the stone is invaded in the ampulla and can not be removed with a stone cutter or gallstone, it can be pushed into the duodenum with a biliary dilator. 8. choledochoscopy: a good fiber choledochoscope, inserted from the common bile duct incision, first to the left and right hepatic sneak, to observe whether the mucosa of the hepatic wall is congested, swollen, narrow or pus-embedded, there are lumens No stones, pustules; try to clip them out. If it fails, the stone can also be set with a set of stone baskets through the choledochoscope. Then turn the speculum to the lower part of the common bile duct, peep into the ampulla, observe the opening and closing of the sphincter and the size of the opening, whether there is stenosis and stone retention, and deal with it accordingly. 9. Drainage of the common bile duct: After the exploration of the common bile duct, the drainage tube should be placed from the dissection. Otherwise, complications such as bile leakage are prone to occur. Use a t-shaped hose that is soft, elastic, and suitable for drainage. The short arm of the t-shaped tube should not exceed 1cm to the hepatic segment, and should not exceed 3cm downward, so as to avoid the end of the tube at the left and right hepatic bifurcation and the lower common bile duct wall, causing pain, pressure ulcer, bleeding or drainage. Wait. Cut both ends of the short arm into a slope, cut a small hole in the short arm arm opposite the long arm, or cut a wall to form a groove shape for later extraction. Sometimes, the bottom side wall can be cut in half to open the lumen. Trim the proper t-shaped tube, fold the short arm, and clip it with a long curved hemostat or a large photo, and feed it into the common bile duct incision. Then loosen up and down a little, confirm that the short arm of the t-shaped tube has been stretched out in the common bile duct. After no folding or twisting, the common bile duct incision is sutured with a thin wire. The needle is inserted at a distance of 1 mm from the edge of the incision. The needle spacing is 2 to 3 mm. Then, the common bile duct was infused with a small amount of saline from a t-tube, and the suture was examined for leaks. Needle should be filled at the leak until it does not leak. The hepatoduodenal ligament incision was sutured intermittently with a thin wire. 10. Drain the abdominal cavity and suture the abdominal wall: Drain the cigarette into the retina hole, and take it along the right side of the liver along with the t-shaped tube, and make a small incision. The incision should not be too small, so as to avoid the t-tube when pulling the cigarette. Bring out. The t-tube was fixedly sutured to the skin, and the cigarette was drained with a safety needle. The omentum is wrapped around the liver, gallbladder, common bile duct and t-shaped drainage tube, so as to prevent the t-shaped tube from pressing the duodenum and forming duodenal fistula; avoid duodenal adhesion to the liver and gallbladder, in the future It may cause difficulty in breaking the liver or duodenum when surgery is performed. Finally, the layers of the abdominal wall are sutured layer by layer.

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