Hepatocholangiojejunostomy through the ligamentum teres approach

Transurethral biliary jejunostomy is used for the surgical treatment of extrahepatic biliary tract cancer. Treatment of diseases: gallbladder carcinoma of the gallbladder Indication Transhepatic bile duct jejunostomy is suitable for: 1. Advanced hilar cancer is not suitable for radical resection. 2. Cholangiocarcinoma or gallbladder carcinoma has metastasis at the hepatoduodenal ligament, which oppresses the extrahepatic bile duct, causing obstruction of the left and right hepatic duct junctions. 3. Benign extrahepatic bile duct stenosis can not be performed in the hilar for technical reasons. 4. The left and right hepatic ducts still communicate or the left hepatic lobe has hypertrophy and hypertrophy. Contraindications 1. Cholangiocarcinoma derived from the left hepatic duct of the hepatic hilum, the left hepatic lobe has been significantly atrophied and fibrotic. 2. The tumor has expanded to the left hepatic duct, and the infiltrating mass of cholangiocarcinoma can be found at the left end of the hepatic hilum. 3. The left lobe of the liver has metastatic nodules. Preoperative preparation 1. The location and extent of biliary obstruction should be accurately estimated. It can be determined by non-invasive methods such as B-mode ultrasound, CT, MRCP, etc. If necessary, PTC and ERCP can be performed before surgery. However, care must be taken to prevent complications such as biliary infections and bile leakage. 2. If PTC and PTCD have been performed before surgery, surgery should be performed at an early stage. After 2 to 3 weeks, there may be a fatal biliary infection due to delayed surgery, and liver function cannot be achieved even after 2 to 3 weeks of drainage. restore. 3. Preoperative PTCD is generally only used in patients with severe obstructive jaundice and the general condition is too poor to perform surgery in time. Under drainage, care should be taken to avoid infection and loss of water and electrolytes. If it can be drained through the endoscope, the effect is better than PTCD. 4. Patients with obvious weight loss and malnutrition began to strengthen intravenous nutrition supplement 1 week before surgery to correct hypokalemia, hyponatremia, anemia, hypoproteinemia, and vitamin K11 supplementation. 5. Oral bile salt preparation. 6. Antibiotic bowel preparation. 7. Oral administration of ranitidine 150mg before surgery. 8. Stomach tube and indwelling catheter. 9. Prophylactic use of antibiotics, in view of patients with obstructive jaundice, acute renal failure may occur after surgery, should avoid the use of antibiotics such as Qingda toxins with nephrotoxicity. 10. The image of the diagnostic imaging shows that the left hepatic duct is dilated and not invaded by the tumor. Surgical procedure Anesthesia and position: 1. Generally, continuous epidural anesthesia can be used. If extensive hepatectomy is needed, general anesthesia can be supplemented by endotracheal intubation. The anesthesia is stable after stress, avoiding hypotension and hypoxia. 2. Pay attention to maintain sufficient urine volume during the operation to balance the salt solution to replenish the liquid. It is better to have a slight excess instead of lacking. 3. In patients with deep jaundice, 20% mannitol 125-250 ml is injected intravenously from the beginning of the operation to maintain diuresis and increase renal blood perfusion. 4. Supine position. Surgical procedure: 1. After laparotomy, the system is examined by the intra-abdominal system to determine the best plan for surgery. 2. Cut the sacral ligament, cut the round ligament of the liver, and ligature. The hepatic side clamp is pulled by a vascular clamp. The left lobe of the liver is pulled downward and the liver is hooked up with a curved hook. In the visceral surface of the round ligament of the liver, there is often a bridge of liver tissue connecting the left inner lobe and the left outer lobe of the liver, which can be cut off and ligated on both sides to better reveal the left sagittal fissure of the liver. The left sagittal portion of the left portal vein branches to the left inner lobe and the left outer lobe of the liver. After incising the hepatic woven group bridge between the left outer lobe and the left inner lobe, the liver round ligament is pulled forward and upward, and the peritoneal covering of the left hepatic fissure is cut, and the sagittal part of the left branch of the portal vein and its passage can be found. To the left inner lobe and the left outer lobe branch, the dilated bile duct of the left inner lobe is often seen in the upper end of the bile duct. The anatomical position of the left intrahepatic bile duct is relatively constant. After the left hepatic duct is divided into the bile duct of the hepatic lobe, it is located at the deep side of the sagittal part of the portal vein, and the upper branch (the second branch) and the lower branch are separated from the left outer lobe. (III segment) hepatic duct, accompanied by portal vein branch. 3. Cut the fibrous tissue of the round ligament and the liver until it is connected to the portal vein, and the branch of the portal vein leading to the left inner leaf and the left outer leaf in its sac, the shallowest branch to the outer side It is the left outer lower segment, the left outer segment of the intrahepatic bile duct is located in the deep side; the hepatic capsule is cut along the left margin of the hepatic sacral ligament, and the liver parenchyma is bluntly separated to achieve the dilated left lower segmental hepatic duct, in 2 Between the thin traction sutures, the bile is obtained by puncture, and it is proved that after the bile duct is correct, it is cut along the axial direction of the bile duct, and the incision is gradually enlarged to both ends, and an opening of about 2.0 cm in length can generally be obtained. Exploring to the hepatic portal, if there is no obstruction in the bifurcation, it can be successfully explored to the right hepatic duct; if it is bile duct bifurcation, only the left hepatic bile duct system can be drained. 4. The 4-0 absorbable synthetic suture is sutured at the leading edge of the bile duct incision, and the suture is long, and is sequentially clamped by a mosquito-type vascular clamp to reduce the difficulty in suturing the anterior wall of the biliary anastomosis. The procedure then turns to the underside of the transverse colon, freeing a Roux-en-Y jejunum for anastomosis. 5. suture close the end of the jejunum fistula, the intestinal fistula is generally about 50cm long, from the transverse colon and the front of the stomach to the upper abdomen and the left lateral lobe of the hepatic duct for side-to-side anastomosis, put a cut in the direction of the hepatic hilum A plurality of silicone rubber tubes with side holes; if the hepatic bifurcation of the hilar is blocked, sometimes only a suitable T-shaped tube can be placed and passed through the jejunal wall of the fistula. Close the gap before the mesenteric membrane and place the intra-abdominal drainage near the anastomosis. complication 1. Bile leakage and biliary peritonitis. 2. Biliary infection. 3. The amount of bile flowing out of the drainage tube is small, thin, pale, and the serum bilirubin decreases slowly or increases, and liver failure may occur. 4. Complications of severe renal obstructive jaundice, such as acute renal failure and stress ulcer bleeding.

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