RU2525009C1 - Method for extraperitoneal antegrade drainage of extrahepatic bile ducts - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: retrograde dilator is inserted through a defect of an extrahepatic bile duct into the left hepatic duct to the round ligament of the liver. That is followed by visually controlled opening of the peritoneum and the left hepatic duct at the dilator tip. A perforated drain tube is inserted into the left hepatic duct following the removed dilator to the level below the defect of the extrahepatic duct. The proximal end of the drain tube is brought out through an additional incision of the anterior abdominal wall onto the skin and fixed. The retrograde dilator is inserted through the defect of the extrahepatic duct into the left hepatic duct to the round ligament of the liver. That is followed by visually controlled opening of the peritoneum and the left hepatic duct at the dilator tip. The perforated drain tube is brought backward following the removed dilator. The proximal end of the drain tube is brought out through the additional incision of the anterior abdominal wall onto the skin and fixed.

EFFECT: method enables using the common kit of instruments to reduce intraoperative injuries when inserting the drain tube; the drain tube is isolated completely from the abdominal cavity; the tube is loosely removed after the extraperitoneal decompression of the bile ducts.

1 ex

Description

The invention relates to surgery and can be used for drainage of extrahepatic bile ducts during operations on them (opening the ducts, iatrogenic damage, resection of the ducts, liver transplantation) for preventing the development of insolvency of bilobiliary and biliary digestive anastomoses or leakage of bile through sutured defects of the bile ducts into the free abdominal cavity with the development of biliary peritonitis.

There is a method of antegrade extraperitoneal drainage of the bile ducts through the round ligament of the liver by a puncture method with a long needle and conducting drainage along the conductor installed through the needle (Vinogradov V.V., Zima P.I. Wounds to the bile ducts during cholecystectomy. Surgery, 1975, No. 10, p. 119-124) or by means of bougienage of the round ligament of the liver with a Dololiotti probe (Blokhin NN, Itin AB, Klimenkov AA Cancer of the pancreas and extrahepatic biliary tract. M., 1982) after application of biliodigestive anastomoses in patients with hepatic duct cancer ov.

The main disadvantage of this method is its limitedness, the implementation of the method is possible only with the most expanded intrahepatic bile ducts due to their obstruction with a cancerous tumor, while with duct injury, liver transplantation, the bile ducts are not expanded ..

There is a method of extraperitoneal drainage of the common bile duct through the round ligament of the liver using a special device (copyright certificate 993922 from 02/07/83) to conduct ligature material. Contraindications to the use of external drainage of the bile ducts through the round ligament of the liver, the authors consider a small diameter of the ducts that does not allow them to draw a curved hollow shaft of the device, the absence of a round ligament of the liver or gross cicatricial changes in it.

The disadvantage of this method is the need to cross the round ligament of the liver, drainage of the duct without visual inspection of the opening of the duct, which can be fraught with damage to the adjacent branch of the portal vein with the formation of gall-venous fistula and hemobilia in the postoperative period. The described device for performing extraperitoneal drainage of the bile ducts is bulky, not manufactured on an industrial scale and cannot be used in the absence of expansion of the bile ducts.

The objective of the invention is atraumatic performed by the method of extraperitoneal drainage of extrahepatic bile ducts of any width.

The problem is solved by the method, namely, that the bougie is carried out in a retrograde manner through the defect of the extrahepatic duct into the left hepatic duct to the round ligament of the liver, the peritoneum and the left hepatic duct are opened under visual control at the tip of the bougie, and the left hepatic duct is opened in the opposite direction through the opened perforated drainage following the extracted bougie below the defect of the extrahepatic duct, then the proximal end of the extracted drainage through an additional incision of the peritoneum round with yazki liver outputted preperitoneal fiber and then through an additional incision of the anterior abdominal wall and fixed on the skin.

In practice, the method is as follows. After identifying a defect in the bile ducts during an injury or after opening the ducts according to indications during surgery, a bougue is made through the defect of the common bile or common hepatic duct to the left hepatic duct to the round ligament of the liver. At the border of the round ligament of the liver and the projection of the left hepatic duct at the gate of the liver, determined by palpation on the bougain, the peritoneum is opened and the front wall of the left hepatic duct at the site of the palpable end of the bougie is found. Above the end of the bougie, under the control of the eye, the wall of the left hepatic duct is opened and the bougie is brought into the defect of the duct wall. A drain pipe with a diameter of 2 mm with a lumen of 1.8 mm is connected to the tip of the removed bougie and it is removed in the distal direction to the duct defect. The peritoneum is opened at the anterior abdominal wall on the round ligament of the liver, an extraperitoneal tunnel is created in the round ligament with Billroth's clamp to the previous peritoneal defect in the region of the opened left hepatic duct. The second end of the drainage is clamped and removed through an additional puncture of the anterior abdominal wall to the left of the wound - access. Defects in the peritoneum are sutured with atraumatic needles with threads 4-0. Thus, the performed drainage is completely isolated from the abdominal cavity. Holes are made on the drainage to create an outflow of bile from the ducts in the postoperative period and after restoration of the posterior wall of the extrahepatic duct defect, drainage is carried out into the intraduodenal part of the duct below the defect. Restore the front wall of the extrahepatic duct. The drainage is fixed to the skin, filled with saline and lowered below the axillary cavity to create a pressure gradient in the bile ducts and in the drainage system. Installation of control drainage in the subhepatic space through an additional incision in the right hypochondrium.

The proposed method for drainage of the bile ducts was developed on the corpses of people. On cadaveric material it is proved that the method of conducting a drainage tube for extraperitoneal decompression of the bile ducts can be carried out with the usual set of tools.

Also, 5 patients with extrahepatic bile duct damage during surgery and 3 patients with cicatricial strictures were operated on.

The following examples illustrate the method of the invention.

Patient V., 52 years old, was admitted to the 2nd surgical department of the City Clinical Hospital No. 67 on 09. 04. 2005 with a diagnosis of acute obstructive cholecystitis, cholelithiasis. Operated through mini-access with Prudkov's recruiting tools. When the duct of the gallbladder was isolated, the common bile duct was crossed and ligated with the cystic duct. When the gall bladder was isolated, damage was detected. Ligatures from the duct have been removed. Produced cholecystectomy with suturing of the cystic duct near the wall of the common bile duct. The access wound of the anterior abdominal wall was expanded to 6 cm. A bougie was made through the lumen of the crossed duct into the left hepatic duct to the round ligament of the liver, and according to the described method, a 2 mm diameter drainage was made through a round ligament with a lumen of 1.8 mm. An absorbable suture 5-0 restored the posterior wall of the common bile duct. Drainage after creating the lateral openings was carried out below the site of damage and the suture on the posterior wall to the intraduodenal part of the common bile duct, and its end is installed above the lumen of the large papilla of the duodenum. The front wall of the common bile duct is sutured. Drainage performed extraperitoneally into the common bile duct through the left hepatic duct extraperitoneally through the round ligament of the liver is fixed in the skin to the left of the access wound. A control drainage to the anastomosis was established through an additional puncture in the right hypochondrium. The postoperative period without complications. The control drain was removed on the third day. When control fistulography through drainage installed in the bile ducts through the round ligament of the liver on day 9, the contrast medium fills the extrahepatic bile ducts evenly. No narrowing of the common bile duct in the area of damage was noted. No streaks. Contrast material flows freely into the duodenum. The drainage tube is removed from the lumen of the duct. Discharged on the 14th day after admission. The patient was examined after 1 year. No complaints.

The method allows to reduce the invasiveness of the operation.

Claims (1)

The method of extraperitoneal antegrade drainage of the extrahepatic bile ducts, which consists in conducting the bougie retrograde through the defect of the extrahepatic duct into the left hepatic duct to the round ligament of the liver, opening under visual control the peritoneum and left hepatic duct at the tip of the bougie through the opened left hepatic duct in the opposite direction, perforated drainage is carried out after the extracted bougie below the defect of the extrahepatic duct, then the proximal end of the extracted drainage through additional incision of peritoneum liver round ligament outputted preperitoneal fiber and then through an additional incision of the anterior abdominal wall and fixed on the skin.