intrahepatic bile duct stone removal

Intrahepatic bile duct stone removal is used for the surgical treatment of hepatolithiasis. Hepatobiliary stones are an integral part of primary bile duct stones. In the past 40 years, the treatment of hepatolithiasis has made great progress. In China, hepatolithiasis still accounts for a high incidence of biliary tract disease. Due to the special anatomical location of the hepatolithiasis, the pathological changes are complex and severe, and the liver and even the whole body are greatly damaged, so it is the main cause of death of non-neoplastic biliary diseases. Most of them are caused by acute suppurative biliary tract infection caused by hepatolithiasis (or calculus falling to the common bile duct or combined with bile duct stricture). In 1965 we summarized 46 cases of biliary tract deaths, and 38 died of acute biliary tract infections and complications of hepatolithiasis. Residual stones in the intrahepatic bile duct are the most common cause of biliary reoperation. We have summarized 702 cases of calculus biliary tract surgery from January 1972 to December 1982, and 156 cases of residual biliary stones, accounting for 22%. Among them, 20/333 cases of residual stones after extrahepatic bile duct stones operation, accounting for 6%; and 136/369 cases of residual stones after intrahepatic bile duct stones operation, accounting for 36.85%, the incidence rate was 6 times of residual stones after extrahepatic bile duct stones operation . At present, the application of choledochoscopy, stone removal, stone dissolving, etc., can solve some of the problems of residual stones, but it is difficult to achieve complete solution; and the damage of bile duct and liver caused by stone obstruction and infection, such as hepatic bile duct stricture, bile duct Expansion, stagnation of the bile, liver fibrosis, atrophy, etc. will not be effectively relieved due to the removal of stones. Therefore, residual stones and coexisting stenosis are often important factors leading to the recurrence of acute suppurative biliary tract infection. How to effectively reduce the high mortality rate and reoperation rate caused by hepatolithiasis is still the basic starting point and focus of surgical treatment of hepatolithiasis. Suppurative inflammation of the bile duct, hepatic bile duct obstruction and hepatocyte damage are the most important concurrent pathological changes of hepatolithiasis. These organic lesions are aggravated by repeated episodes of infection, and these changes are often not limited to the area where the stone is present, but involve the entire biliary system to varying degrees. Repeated infections may also lead to hepatobiliary adenocarcinoma and hepatobiliary adenomatous hyperplasia. Hepatobiliary obstruction is a core factor affecting prognosis and is the key to surgical treatment. The location of the obstruction determines the extent of the lesion, and the extent of the obstruction and the length of the time determine the severity of the lesion. If the obstruction is not relieved, it can cause a series of secondary lesions, such as biliary ulcer, perforation, hemorrhage, biliary-derived liver abscess, hepatic bile duct stenosis, hepatic lobe atrophy, biliary cirrhosis, and even hepatic vein occlusion and gallbladder Thrombosis-induced pulmonary thromboembolism. Can also be complicated by underarm or subhepatic abscess, biliary peritonitis and biliary formation. These highlight the serious harm of hepatolithiasis and the urgency and necessity of early treatment. The basic requirements for surgical treatment are to remove obstruction, remove lesions, and smooth drainage. A large number of clinical practice data show that in all kinds of surgical methods, any treatment that meets these three aspects of the treatment requirements will be effective; otherwise, the residual stone rate and recurrence rate will be high. Treatment of diseases: gallstones, acute cholecystitis Indication 1. Patients with recurrent acute suppurative cholangitis or hepatic cholangitis with or without jaundice, and imaging data showing patients with hilar or intrahepatic bile duct dilatation and stones. 2. Clinically diagnosed as biliary septic shock, biliary hemorrhage, liver abscess, and patients with hepatic bronchial fistula. 3. In the past, there was a history of hepatolithiasis surgery, and the postoperative clinical symptoms were repeated. 4. Repeated episodes of suppurative cholangitis after upper abdominal trauma, liver trauma, and hilar trauma. 5. Patients with obstructive jaundice, hilar and intrahepatic bile duct dilatation, stone formation or biliary formation after cholecystectomy. 6. Grade 1 to 2 stones in the hepatic duct. 7. Intrahepatic bile duct stones were not cleared after biliary drainage in acute cholangitis. 8. In the past, after biliary tract surgery, residual stones or stones in the intrahepatic bile duct recurred and caused symptoms. Contraindications 1. Local or biliary purulent infection has not been controlled. 2. There are no obvious clinical symptoms of peripheral intrahepatic bile duct stones. 3. There are still T-shaped tubes that can be removed by fiber choledochoscopy through the T-tube sinus. 4. The lack of technical conditions for the implementation of intrahepatic bile duct surgery or the patient's condition can not withstand major surgery. Preoperative preparation Hepatolithiasis, hepatobiliary stenosis, especially those with recurrent seizures of severe cholangitis, long-term obstructive jaundice and biliary fistula, local and general conditions are often poor, and should be carried out at the same time as various examinations and diagnoses Thoughtful preoperative preparation. 1. Supplement blood volume, maintain water and salt metabolism and acid-base balance, especially pay attention to the correction of chronic water loss and hypokalemia. 2. Strengthen and improve the systemic nutritional status of patients. Give a high-protein, low-fat diet and add enough calories and vitamins. Patients with obstructive jaundice should be injected with vitamin K11. Some patients also need fluid replacement and blood transfusion. In patients with complete biliary fistula and hepatic insufficiency, intravenous nutritional support is often required. 3. Check the coagulation mechanism and correct any abnormalities that may occur. Comprehensive analysis was performed together with the results of liver function tests to evaluate liver reserve and metabolic function. 4. Pay attention to protect liver function. Repeated episodes of biliary tract infection and prolonged obstructive jaundice often cause varying degrees of liver damage. If you have biliary cirrhosis, you should pay attention to active liver protection. Patients with long-term external drainage tube, if the daily bile flow is many and the color is light, it is often a sign of liver dysfunction. The inversion of the ratio of white and globulin indicates that the compensatory function of the whole liver is in an unfavorable condition. If you have splenomegaly and ascites, you should first do liver protection treatment. After you have improved, consider the staged treatment. 5. Investigation of bile bacteriology and antibiotic susceptibility testing to use antibiotics more rationally. In some complicated cases, it is often necessary to start systemic application of antibiotics 2 to 3 days before surgery to help prevent surgery or angiography and stimulate cholangitis. If the operation is performed during the onset of cholangitis, penicillin or metronidazole (metidazole) should be administered to control the mixed infection of anaerobic bacteria. 6. Protect and support the body's emergency response capabilities to help smooth out the post-operative traumatic response. These patients have been repeatedly attacked by biliary tract infections and multiple operations, often with physical depletion; and most of them have a history of treatment with different degrees of glucocorticoids, systemic response is low, should pay attention to support and protection. In the operation, hydrocortisone 100 ~ 200mg was intravenously instilled, and 50-100 mg per day can be instilled within 2 days after surgery, which often receives good results. 7. For patients with external drainage, the preparation of the skin of the mouth should be carried out as soon as possible. For excessively long granulation tissue, it should be cut off. For local inflammation and skin erosion, the dressing should be changed frequently and wet if necessary. For mouthwashes with digestive juices, apply zinc oxide paste coating protection. Keep your mouth clean and perform surgery when your skin is healthy. Deworming should be routinely performed after admission. Stomach tubes and catheters should be placed before surgery. Surgical procedure 1. Incision: The oblique incision in the right upper abdomen is the best choice for incision. Followed by the right upper rectus abdominis incision, but not as good as the right upper abdomen rib oblique incision, the room for maneuver is small. 2. Exposing the hilar bile duct: This is the key to this procedure. Care should be taken to separate the adhesion of the hepatoduodenal ligament to the hilar. And pull the liver up. 3. Open the common bile duct and the common hepatic duct to fully expose the opening of the left and right hepatic ducts and the caudal lobe. 4. Remove the stones in the first and second branches of the left and right hepatic ducts one by one with the applicable gallstone spoon. In some cases, there is no stone in the hepatic duct of the hepatic hilum, or the stone has been removed smoothly, and there is an incarceration or a cluster of isolated stones in the left outer lobe or the right anterior lobe. At this time, the patient's liver has no obvious damage, and it is not appropriate or necessary to perform partial hepatectomy. Hepatic parenchymal bile duct incision and stone drainage can be used. 5. Liver parenchymal bile duct incision of left hepatic lobe isolated gallstones. The left outer lobe of the liver was freed and the intrahepatic stones were positioned with a left hand grip. The hepatic capsule was cut longitudinally along the direction of the left hepatic duct, and the liver parenchyma was bluntly separated by the shank, and the dilated bile duct and stones were effectively exposed. A small amount of hemorrhage in the liver parenchyma can be electrocoagulated or sutured to stop bleeding. However, care should be taken to avoid damage to the portal branch associated with the hepatic duct. The anterior wall of the left hepatic duct was sutured by a thin wire and cut along its longitudinal axis. The stones were removed one by one by the instrument, and the connection with the hepatic hilum was ensured. A T-shaped tube of appropriate size is built into the left hepatic duct, the hepatic duct is sutured and the liver tissue is sutured to complete drainage of the left hepatic duct. 6. Isolated or incarcerated stones located in the upper branch of the anterior segment of the liver, often with variations in the junction of the hepatic duct, often difficult to remove effectively. At this time, the stone is shallower from the surface, and often the locust is positioned, and the hepatic round ligament is pulled down by the assistant to fix the liver. Cut the liver capsule, bluntly separate the liver parenchyma, reach the surface of the right anterior superior hepatic duct, use the silk thread as the second suspension traction, cut the hepatic bile duct, and take the net stone. It should be explored and affirmed for its communication with the hilar bile duct. Sometimes, the right upper anterior bile duct of the liver is distorted and opened in the transverse section of the left hepatic duct, and often has a stenosis. Place a suitable T-shaped tube. For the narrow part of the left hepatic duct, a certain length of the T-shaped tube can be reserved as a support to avoid stenosis and regenerate the stone. complication 1. Postoperative bacteremia. It is caused by surgery. Anti-infective drugs should be applied during surgery, pay attention to soft operation during operation and protect organ tissues. 2. Bile leakage. If there is a small amount of bile overflow in the drainage port, the drainage should be kept smooth, and should not be left in the abdomen; if the amount of bile exudation is large, if necessary, another drainage or negative pressure can be used to attract the drainage at the drainage port. 3. The drainage tube is blocked. Can be expressed as postoperative biliary tract infection, bile leakage, obstructive jaundice. The occurrence may be due to: 1 obstruction of residual stones in the liver; 2 oozing or hemorrhage of the biliary tract, obstruction of coagulation accumulation; 3 drilling of aphids; 4 small stones accumulating in the drainage tube, and timely treatment should be given accordingly. However, water flushing should be avoided within 72 hours after surgery. If you enter the mites, you can use a large syringe to draw the flow tube, while sucking and kneading, you can often suck out the mites. After 10 to 12 days, there is still obstruction, and the T-shaped tube can be removed, and the catheter of corresponding size is placed into the drainage.

The material in this site is intended to be of general informational use and is not intended to constitute medical advice, probable diagnosis, or recommended treatments.