Percutaneous transhepatic cholangiography (PTC)

Mainly used in patients with obstructive jaundice to understand the location, extent and cause of biliary obstruction. Treatment of diseases: gallstone intestinal obstruction, cholestatic jaundice Indication Mainly used in patients with obstructive jaundice to understand the location, extent and cause of biliary obstruction. Contraindications 1. The blood coagulation mechanism has serious obstacles. 2. Severe acute suppurative obstructive cholangitis. 3. Liver and kidney function is very poor. 4. The patient is too old and should be filled with poor general condition. Preoperative preparation 1. Clean the enema one night before the angiography and give a sedative. 2. Give sedatives one hour before angiography, but morphine is forbidden to avoid confusion caused by Oedic sphincter spasm. 3. Before the angiography of the abdomen, observe whether there is an inflatable bowel under the liver to avoid accidental injury during puncture. 4. For iodine allergy test. 5. For the determination of prothrombin, such as prolongation should be given vitamin K to correct. 6. Preparation needle: 5 or 6 slender needle, or 15cm long, 0.7mm outer diameter, 0.5mm inner diameter, 30° needle bevel, with a flexible steel core, or 76 -2 type plastic outer casing puncture needle, length 25 ~ 28cm, outer diameter 1.3mm, inner diameter 0.9mm. Surgical procedure Intercostal intercostal puncture (1) Puncture approach, generally 8 to 9 ribs or 9 to 10 rib gaps in the right middle line. When conditions are available, it is best to observe the liver variability directly under X-ray monitoring and adjust the height, direction and depth of the puncture point. (2) Disinfection, toweling, puncture point local anesthesia. (3) According to the puncture point selected above, the needle is pointed in the horizontal direction, and the tip of the needle points to the tip of the xiphoid. (4) Generally, the needle is about 8 to 13 cm, and the bile duct is thicker. When the puncture needle penetrates into the bile duct, there is a sense of breakthrough. At this point, pull out the needle core, replace the syringe, and slowly withdraw the needle, while pumping, if the bile is pumped, stop the retreat, indicating that the needle tip is in the bile duct. If the bile is not extracted and the needle is removed to 1/2 of the needle path, the needle should be removed to the skin under the puncture failure, and the direction should be changed slightly before puncture. Continue 4 to 5 times, still have not pumped bile should stop operation, so as not to damage excessive liver tissue. (5) The following method can also be used. When the needle is inserted to the appropriate depth, a small amount of contrast agent is injected first, and the position of the needle is judged under the X-ray screen display. If the needle is mistakenly inserted into the blood vessel, the contrast agent will be diluted and quickly flow away; if the needle is in the liver parenchyma, the contrast agent will remain stationary; if the contrast agent enters the hepatic bile duct, the contrast agent will slowly flow to the hepatic hilum. (6) After successful puncture, fix the needle, connect the syringe with plastic tube, extract part of the bile, and send the bacteria to culture; then slowly inject 20% to 50% of the diatrizoate 20ml. When the patient feels that the liver area is slightly inflated, the injection should be stopped and the film taken. If the bile duct is highly dilated, the contrast dose can be appropriately increased. (7) After taking the film, try to suck out the bile mixed with the contrast agent to avoid leakage of the gallbladder. If the photo is satisfactory, you can end the check. If you are not satisfied, you can inject the contrast agent again for filming. 2. Transabdominal puncture method: the puncture site is selected under the right rib margin, the puncture point is 2cm below the xiphoid process, the midline of the abdomen is 2cm to the right, and the puncture point is at an angle of 40° to the tabletop, and the puncture is directed to the liver. The applied puncture needle is preferably 12 cm long. This method applies to patients with enlarged liver. 3. Transperitoneal puncture: This method is performed through the naked area behind the liver. Since the naked area is constant even when the liver is swollen, and the puncture does not damage important organs, biliary peritonitis or intra-abdominal hemorrhage does not occur. Right sacral nerve block before angiography. The method was to use 2% increase in the anterior border of the sternocleidomastoid muscle on the right clavicle, and the activity was reduced, indicating that the sacral nerve block was effective. Then the patient took the prone position, and after the normal local anesthesia was taken from the upper midrib of the right 11 ribs 6 to 7 cm from the posterior midline, the liver was pierced with a 15 cm long needle, and the needle was slightly pointed into the upper body. When the needle was inserted 10 to 12 cm, the aforementioned The method of withdrawing the needle and extracting the bile indicates that the puncture is successful. The contrast agent and the filming procedure are the same as before. This approach is far less than the success rate of puncture puncture through the road. complication Impaired liver function.

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