1. Intraoperative diagnosis of bile duct injury
Timely detection and treatment during operation is ideal, because the success rate of tissue health repair is high, and the difficulty, passivity and danger of reoperation are avoided.
(1) When the extrahepatic bile duct is mistakenly ligated but not cut off, it is generally only necessary to remove the ligation. However, if the ligation is too tight for a long time, or the bile duct is not smooth after loosening, it is necessary to consider cutting and placing T tube for drainage to prevent necrosis or stenosis. When the bile duct wall is necrotic due to blood supply disorder, this section of bile duct can be removed and end-to-end anastomosis or cholangioenterostomy can be performed.
(2) End-to-end anastomosis should be performed for the transection injury of extrahepatic bile duct, and the lateral wall of common hepatic duct (bile duct) should be cut to place T tube for drainage, so as to free the lateral peritoneum of duodenum and reduce the anastomosis tension. Anastomosis requires good opposite ends and uniform needle spacing, and generally 3-0 needles are used. Roux-en-Y cholangioduodenal anastomosis or cholangioduodenal anastomosis should be performed if the bile duct injury site is high, end-to-end anastomosis is difficult, or the resection section of common bile duct is too long, and the retroperitoneal tension is still high after free duodenum, and stent drainage should be placed for more than 6 months after operation. Roux-en-Y anastomosis is the best.
(3) In the operation of extrahepatic bile duct laceration, most of them are vertical lacerations caused by violent traction. If the laceration is not wide or the injured bile duct is less than 50% of the diameter, the injured bile duct wall should be sutured horizontally and T tube should be placed for external drainage. When placing, the incision should be redone in the upper or lower half of the injury, and the long arm of the T tube should be supported by the suture. Care must be taken not to place the T-tube from the original wound to avoid postoperative stenosis. If the defect is large but the bile duct is still partially connected, the gallbladder wall, jejunum wall, ileum wall, gastric serosa, umbilical vein, ligamentum teres hepatis and other blood-supplied tissues can be used for repair, and internal support and drainage can be added. Serous epithelial tissue can tolerate bile invasion well, with strong repair ability and good effect.
(4) Once the injury of the lower segment of common bile duct is found, it should be treated according to the specific situation: ① The false channel is small, and there is no obvious bleeding, only T tube drainage and abdominal drainage are used; ② The false channel is large, turn the head of pancreas and duodenum to the left to explore the false channel. If the false passage leads to the pancreatic parenchyma and intestine, and there is no bleeding or bleeding has stopped, T tube is used to drain the common bile duct, and cigarette is used to drain the pancreatic head and duodenum. Postoperative drainage should be kept unobstructed and can generally be cured. Because the anatomy of pancreatic head and duodenum is complicated, try to avoid complicated surgical treatment.
2. Early diagnosis of bile duct injury after operation.
When bile duct injury is found early after operation, the original operator should be asked to recall the operation process, and abdominal puncture, B-ultrasound and other auxiliary examinations should be performed to assist diagnosis. Biliary obstructive injury is mostly caused by accidental ligation of extrahepatic bile duct, which should be repaired or released as soon as possible. Bile leakage is the main manifestation, depending on the drainage situation. If bile leakage is small and there are no symptoms of peritonitis, conservative observation can be made. If the drainage is not smooth or bile peritonitis has occurred, surgical exploration should be actively carried out. For those who are injured within 72 hours and are generally in good condition, it is feasible to reoperation for primary repair. Those who have been injured for more than 72 hours have obvious local tissue inflammation and edema due to secondary infection. Generally, biliary drainage should be done first as a transitional treatment, and then radical treatment should be done 2 ~ 3 months later. Or put an effective double-cavity drainage tube in the most suitable position, plus a douche tube, and continue douche for 24 hours, so that negative pressure suction can promote inflammation to subside as soon as possible. At this time, it is very dangerous to force radical surgery, and violating this principle will often cause serious complications.
3. Late biliary stricture
Bile duct stenosis occurs several months and years after operation, and patients can't be diagnosed for a long time after symptoms appear. Because of the long course of disease, patients often have liver function damage, and the general situation is relatively poor. Therefore, the treatment of advanced bile duct stenosis is more complicated. In addition to surgical treatment, the choice of surgical opportunity, the improvement of preoperative preparation and postoperative treatment are all very important.