Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_738_Библиотеки_им_академика_М_И_Перельмана.pdf
102 Atlas of Gastrointestinal Surgery: Gall Bladder and Biliary Tract
The hepaticojejunostomy is performed in a single layer
Percutaneous
catheters
Common
hepatic
duct
using multiple interrupted 4-0 synthetic absorbable sutures.
The posterior wall is placed in the jejunum prior to making an
enterotomy. The sutures are placed into the submucosal
layer of the jejunum and through and through the duct
(8). All sutures are placed before they are tied.
8
Posterior row
of anastomosis
Roux-en-Y
jejunal loop
9
Once the sutures are secured, an enterotomy is carried out in the Roux-en-Y loop with the electro-
Enterotomy
cautery (9).
The posterior layer of sutures is then divided and the two biliary
catheters inserted into the Roux-en-Y loop (10). These are not
exchanged for transhepatic Silastic biliary stents because the proximal biliary segment is normal, and a good mucosa-to-mucosa
anastomosis can be performed. The two percutaneous transhepatic biliary catheters are not used as long-term stents,
but will be left in for a month or 6 weeks merely to
decompress the biliary anastomosis during healing. They
are mostly used to help the surgeon identify the biliary
Resection of Choledochal Cyst 103
Percutaneous catheter
10
structures at the time of surgery. The stents will be
removed during an outpatient visit.
11
Posterior row
of anastomosis
The anterior row of sutures is placed using a single layer of
interrupted 4-0 absorbable synthetic sutures placed through
and through both duct and bowel (11). All sutures are placed
before they are tied. As mentioned previously in this instance
since the common hepatic duct was normal, only one percutaneous
biliary catheter needs to be placed.
104 Atlas of Gastrointestinal Surgery: Gall Bladder and Biliary Tract
Percutaneous
biliary catheter
Percutaneous
catheter
Hepaticojejunostomy
Roux-en-Y jejunal loop
Transverse
mesocolon
tacked to
jejunal loop
12
Transverse colon
End-to-side
jejunojejunostomy
The Roux-en-Y loop is tacked to the rent in the transverse mesocolon with interrupted 4-0 silk sutures to prevent small
bowel herniation (12). The two percutaneous biliary catheters were placed preoperatively and already have exit sites
through the left upper quadrant and the right chest. The catheters are placed to allow bile-bag drainage by gravity. Five
days after surgery cholangiography is performed. If no leaks are seen, the catheters are internalized by placing stopcocks
or heparin locks on the ends. Patients are taught to irrigate the catheters twice a day with 20 mL of saline. The catheters
are removed 4 to 6 weeks following surgery. The anastomosis is drained with a closed suction Silastic drain brought out
through a stab wound in the right upper quadrant.
Transhepatic Stenting for Caroli’s Disease
Operative Indications:
Caroli’s disease is a rare disorder that is generally classified amongst the choledochal cysts. Type IV and Type V choledochal cysts include intrahepatic dilatation. If the intrahepatic dilatation is associated with an extrahepatic choledochal cyst,
it is classified as a Type IV. Type V is only intrahepatic dilatation. Even more unusual is Caroli’s disease limited to the left
lobe of the liver. I have never seen it limited just to the right lobe, but left-lobe-only involvement does occur. Since Caroli’s
disease is associated with a substantial incidence of the development of cholangiocarcinoma, the treatment for left-sided
Caroli’s disease is left hepatic lobectomy. Someday, when liver transplantation is a totally safe procedure with excellent
long-term survival, patients with bilateral Caroli’s disease
will probably be treated routinely with liver transplantation. Data from Japan suggest that, if one follows patients with Caroli’s disease long
enough, virtually all of them will eventually
develop cholangiocarcinoma. Currently,
however, patients with bilateral Caroli’s
disease, in the absence of evidence of
cholangiocarcinoma, should be stented
with bilateral Silastic transhepatic biliary
catheters. Prior to surgery, patients with
bilateral Caroli’s disease should have percutaneous transhepatic biliary catheters
inserted into both right and left intrahepatic ductal systems, and distally into the biliary
Intrahepatic
ductal cysts
Gall bladder
12
Common duct
Percutaneous biliary
catheters
tree (1). If they are passed through the
ampulla into the duodenum, the risk of pancreatitis is incurred.
106 Atlas of Gastrointestinal Surgery: Gall Bladder and Biliary Tract
Operative Technique:
Patients are explored through a right subcostal incision, occasionally extended over to the
left. At the time of laparotomy, the liver and extrahepatic biliary tree should be carefully examined for evidence of cholangiocarcinoma. Intraoperative ultrasound should be utilized. Generally, the liver will be normal in appearance. The gall bladder is mobilized, the
extrahepatic biliary tree is dissected free, and the distal common bile duct is looped with
a vessel loop. The distal common duct is then divided with the electrocautery (2).
Mobilized
gall bladder
2
Choledochotomy
Duodenum
Following division of the distal common duct, the
transhepatic biliary catheters are extracted and
the distal biliary segment oversewn with a
series of interrupted 3-0 silks. The proximal
Transhepatic Stenting for Caroli’s Disease 107
biliary segment is dissected up to the common hepatic duct. The hepatic duct is
divided (3) and the specimen is
removed from the operative field. Since
both right and left hepatic ducts will be
stented with large-bore, thick-walled
Silastic transhepatic stents, the extrahepatic biliary tree and ampulla will not
accommodate these stents. Therefore
the extrahepatic biliary tree is excised
and, after stent placement, is anastomosed to a Roux-en-Y jejunal loop.
Division of common
hepatic duct
3
Oversewn distal
common duct
Duodenum
Percutaneous
biliary
catheters
108 Atlas of Gastrointestinal Surgery: Gall Bladder and Biliary Tract
4
Partially
removed
biliary
catheter
Partially
removed
biliary
catheter
Guidewire
Common hepatic duct
Endoscopic view
Guidewire
Guidewire
Guidewires are threaded through the transhepatic biliary catheters on both the right and left to ensure that the
pathway is maintained if a catheter should break or
become dislodged in the subsequent manipulations. The
biliary catheters are then backed out from the top of the
liver. Using the guidewires, a flexible choledochoscope
can be inserted to examine the intrahepatic biliary tree
Flexible
choledochoscope
Cystic
dilation
5
Biopsy
Biopsy of
suspicious
lesion
(4). This is important since there is a significant incidence
of cholangiocarcinoma in Caroli’s disease. Suspicious areas
should be biopsied (5).
Guidewire
Choledochoscope
Intrahepatic
ductal cysts
Transhepatic Stenting for Caroli’s Disease 109
Percutaneous
biliary catheter
6
Coudé
catheter
Common hepatic duct
Percutaneous
biliary catheter
Small Coudé
catheter
Silastic biliary stent
Following choledochoscopy, the biliary
catheters are reinserted over the guidewires
down through the common hepatic duct. A
16 French Silastic transhepatic biliary stent is
threaded over the guidewire and on the tran-
shepatic biliary catheter and sutured in place. A
mattress suture of 2-0 silk is used. The biliary
catheter is withdrawn, thus placing the 16 French
Silastic stent in its tract (6). Over the next several months, one
may decide to upsize the Silastic biliary stents to an 18 French or even a 20 French. This can easily be done in the catheterization laboratory following discharge from the hospital and when the tracts are secure. The side holes of the Silastic stents
are positioned so they reside within the liver and in that portion of the stent that extends beyond the common hepatic
duct and which will be placed in the Roux-en-Y loop. A Roux-en-Y jejunal loop 60 cm in length is constructed as previously described. It is brought up into the right upper quadrant in a retrocolic fashion, on top of the second and third
portions of the duodenum, so that it rests without tension in the subhepatic space.
110 Atlas of Gastrointestinal Surgery: Gall Bladder and Biliary Tract
Silastic biliary stent
A single-layer anastomosis is performed using
interrupted 4-0 synthetic absorbable material. The posterior layer is placed prior to making an enterotomy. These
sutures pass into the submucosal layer of the bowel and through
and through the duct (7). Each is held with a hemostat.
Common hepatic duct
7
Posterior row of
anastomosis
Roux-en-Y
jejunal loop
Enterotomy
8
Once the sutures are all placed, they are secured, and an
enterotomy is performed using the electrocautery (8).
The back row of sutures is divided and the stents are placed in the
Roux-en-Y loop (9).
Transhepatic Stenting for Caroli’s Disease 111
Silastic biliary stent
10
Anterior row of
anastomosis
9
The anastomosis is completed with an anterior row of interrupted 4-0 synthetic absorbable sutures placed in a simple through-and-through fashion (10). All sutures are
placed before they are secured.