RU2568765C1 - Method for intraoperative detection of bile leakage accompanying hepatectomy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: Venofer is used as a contrast medium. The bile duct system is enhanced before the stage of hepatectomy. The common bile duct is clamped with a bulldog vascular clamp and cannulated through the cystic duct remnant. The bile duct system is filled with a contrast solution of Venofer in a ratio of 2 ml in 200 ml of normal saline. The contrast solution continuously flows from a bottle through an infusion device. The bile duct filling is assessed as the contrast medium stops dropping. The liver pulp excision is performed. The resection involves monitoring the bile duct system integrity by visualising the enhanced bile ducts as shown by the contrast medium continuing dropping in a drop tube. Once the liver pulp excision is terminated, the check infusion of the solution is performed to detect any defects of the bile duct system integrity along the hepatectomy.

EFFECT: method provides the complete and uniform filling of the bile duct system by using the infusion device, enables visualising clearly the enhanced bile ducts of difference sizes, the presence of bile leakage and its origin before, during and after the hepatectomy, monitoring the bile leakage process by using Venofer and beginning the contrast enhancement procedure before the resection.

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Description

The invention relates to medicine, to the field of abdominal surgery, in particular to liver surgery and directly to the technique of performing liver resections of various volumes and complexity.

There is a method of intraoperative detection of bile leakage from the surface of the liver parenchyma resection when performing large resections of this organ, called the "white test", which is the prototype of the invention and consists in the introduction of a sterile 5% fat emulsion with a syringe through a cannula inserted into the bile duct through the stump of the cystic duct at the end of the resection liver [S. Nadalin, J. Li, H. Lang et al. "The white test: a new dye test for intraoperative detection of bile leakage during major liver resection," Archives of Surgery, vol. 143, no. 4, pp. 402-404, 2008]. In this case, the distal bile duct is pinched with fingers. By the appearance of an emulsion on a section of the liver, the presence of defects in the bile ducts that are sutured is judged. The remains of the emulsion are easily washed off with physiological saline. Residues from the bile duct are washed out by infusion of physiological saline under low pressure. The disadvantages of this method:

1. Compression of the common bile duct is carried out manually, pinching it with your fingers, which does not always ensure proper tightness. Finger clamping of the common bile duct to create an airtight bile duct system creates technical difficulties in the wound (turns off the surgeon’s hand and reduces visibility in the wound),

2. the fat emulsion is washed off very quickly, which requires repeated injections,

3. the total filling of the entire gall tree is not achieved, in connection with which small bile ducts can be missed and not ligated,

4. the coloring matter is introduced by the authors after a liver resection, which does not allow to visualize and process the bile ducts already during the resection,

5. it is impossible to monitor the tightness of the bile ducts during dissection of the liver parenchyma to reduce the volume of the coloring matter supplied from the vial in the absence of tightness in the bile duct system, since the substance is injected by jet using a syringe,

6. requires the introduction of a rather expensive substance.

Also known is a method of intraoperative diagnosis of bile flow, which consists of introducing a fluorescent indocyanine green into the common bile duct with a syringe in a similar way through the stump of the cystic duct [T. Sakaguchi, A. Suzuki, N. Unno et al., "Bile leak test by indocyanine green fluorescence images after hepatectomy," American Journal of Surgery, vol. 200, no. 1, pp. e19-e23, 2010]. Areas of bile leakage along the line of liver resection are studied using the rays of an infrared camera. The disadvantages in our opinion are:

1. the complexity of the method due to the use of additional equipment - infrared camera,

2. the total filling of the entire bile tree is not achieved, in connection with which small bile ducts can be missed and not ligated,

3. the coloring matter is introduced by the authors after a liver resection, which does not allow visualization and processing of the bile ducts already during the resection and, as a result, can increase the number of bile ducts in the postoperative period,

4. it is impossible to monitor the tightness of the bile ducts during dissection of the liver parenchyma to reduce the volume of the coloring matter supplied from the vial in the absence of tightness in the bile duct system, since the substance is injected by jet using a syringe,

5. the use of fairly expensive components.

An object of the invention is to increase the efficiency of intraoperative detection of the bile ducts, the fact of bile duct and the source of bile duct along the line of resection of the liver from the initial moment of dissection of its parenchyma, as well as the possibility of intraoperative assessment of the tightness of the bile duct system by staining the bile duct with a dye entering the pinched instrument and cannulated common bile duct duct from the vial through the device for infusion of infusion solutions (system with a dropper) and a monitor tion dye motion in a drip system.

The essence of the invention lies in the fact that before the stage of liver resection, the distal compression of the common bile duct is initially performed, which is done not with fingers, but with the help of a vascular clamp of the Bulldog type, cannula of the common bile duct (cystic duct) is filled, and the bile duct system is filled dye that enters the cannula from the vial through the device for infusion of infusion solutions (system with a dropper) continuously.

A dark brown venofer solution (2 ml per 200 ml of physiological sodium chloride solution) is used as a coloring matter. This coloring matter is less intensively washed out of the bile ducts. This allows you to visualize both whole and crossed bile ducts immediately from the moment of dissection of the liver parenchyma, as well as monitor the tightness of the bile ducts during resection by the movement of the dye in the dropper system and reduce the volume of the dye in the vial in case of depressurization of the bile duct system . When crossing a sufficiently large bile duct, the bile duct system is depressurized with the contents flowing out, which leads to a decrease in the volume of the dye in the vial of the closed system, which is manifested by the resumption of the movement of the solution in the dropper of the system and allows you to monitor this process, and also serves as a signal to find the place of bile duct.

The method is illustrated by figure 1, where: 1 - common bile duct (choledochus), 2 - clamp type "Bulldog", 3 - stump of the cystic duct with cannula, 4 - bottle with a dye and a device for infusion of infusion solutions (system with a dropper), 5 - catheter for infusion; 6 - intrahepatic bile ducts.

The method is as follows. Under total intravenous anesthesia with mechanical ventilation after treatment of the surgical field with a solution of skin antiseptic twice, one of the laparotomy variants is performed with mobilization of the corresponding half of the liver, dissection of the portal elements of the liver and their identification are performed, and the distal section of the common bile duct is isolated in the first stage (1), which a bulldog-type vascular clamp (2) distal to the site of inflow of the stump of the cystic duct introduced by the catheter, after which the common bile duct is cannulated with thin PVC catheter through the stump of the cystic duct (3). Next, a system for dropping the administration of liquids with a filter (4) filled with a sterile staining solution (2 ml venofer solution of 200 ml of physiological sodium chloride solution) is immediately connected to the catheter and a continuous drip infusion into the common bile duct through the catheter is performed (5), evaluate the filling of the bile ducts (6) with a solution to stop the drip of the dye, after which they begin to perform the intersection of the liver parenchyma and its resection, visualize and ligate the crossed bile ducts. The tightness of the bile duct system is monitored during liver resection to resume the drip of the dye, and after the end of the liver parenchyma resection, a control jet injection of the solution is performed to detect defects in the tightness of the bile duct system along the liver resection line, while the bile ducts are ligated or stitched. The dye is completely washed out by jet injection of an isotonic sodium chloride solution, the catheter is removed from the stump of the cystic duct, the duct stump is ligated with a thread with a long resorption period. The operation is completed as standard.

Technical result: the use of this method during resection of the liver parenchyma allows you to clearly visualize the contrasted bile ducts of different calibers (whole or crossed), requiring ligation in one way or another, the fact of bile duct and its source, allows you to monitor the process of bile duct.

Clinical Example

Patient M.V., 38 years old, was admitted with a diagnosis of giant cavernous hemangioma of the right half of the liver. Operation: right-sided hemihepatectomy under conditions of intraoperative contrasting of the bile ducts and intraoperative ultrasound. Under total intravenous anesthesia with mechanical ventilation, the upper median laparotomy was performed with a bypass of the umbilical ring on the left. During revision of the abdominal cavity, an intense tumor-like formation of a cherry color was found, occupying the entire right half of the liver. A decision was made to perform right-sided hemihepatectomy. The liver is mobilized with a dissection of the sickle, coronary, right triangular, hepatic-renal ligaments. Produced "from the neck" cholecystectomy with separate ligation of the cystic duct and artery. The distal section of the common bile duct above the duodenum was isolated. The common bile duct distal to the site of inflow of the cystic duct is closed by a soft vascular clamp of the Bulldog type. A thin polyvinyl chloride catheter is inserted into it through the stump of the cystic duct. A drip infusion of a venofer solution was started (2 ml per 200 ml of physiological sodium chloride solution). After the movement of the dye in the filter is stopped, the systems are identified, isolated and ligated after preliminary tests with compression of the right hepatic artery, right portal vein, ligated, crossed. On the line of demarcation, a right-sided hemihepatectomy was performed with clipping and ligation of tubular structures at the clamps. The bile ducts, painted in color from dark brown to black, are carefully clipped and sutured with separate atraumatic sutures with 4/0 proline. Twice during the resection, the resumption of the solution from the vial was noted, which served as a signal to search for non-ligated bile ducts. A revision of the liver resection line was carried out and non-ligated bile ducts were additionally sutured. After completion of the liver resection, a control jet injection of the solution was carried out, and there was no leakage of the dye from the liver resection line. 60 ml of physiological sodium chloride solution was introduced through the catheter, after which the catheter was removed, the stump of the cystic duct was twice ligated with 3/0 Vicryl. The operation was completed by drainage of the subhepatic and subphrenic space with three standard drains and layer-by-layer wound closure. In the postoperative period, bile ducts were not noted. The postoperative period was smooth.

Eight patients who underwent intraoperative contrasting in the described manner were operated on the basis of the Federal State Budget Health Institution ZSMTS FMBA of Russia in the department of portal hypertension. The next postoperative period was uneventful, no bile ducts were noted. All patients were discharged home at the optimum time in satisfactory condition.

Claims (2)

1. The method of intraoperative detection of bile leakage when performing a liver resection, including intraoperative contrasting of the bile ducts, characterized in that the venofer is used as a contrast, and the contrast of the bile duct system is performed before the liver resection stage begins, while the common bile duct is pinched by the vascular clamp type "Bulldog" and cannulated through the stump of the cystic duct, then the bile duct system is filled with a contrast solution of venofer in wearing 2 ml per 200 ml of physiological saline, continuously flowing from the vial through the device for infusion of infusion solutions, the filling of the bile ducts with a solution to stop droplet flow of dye is evaluated, and then the liver parenchyma is resected, during which the tightness of the bile duct system is monitored by visualizing the contrasted bile ducts ducts and to resume the drip of dye in the dropper, and after the end of the resection of the liver parenchyma, a control truynoe administration solution for revealing defects in tightness biliary system via line liver resection. 2. The method according to p. 1, characterized in that when detecting defects in the tightness of the bile duct system along the line of resection of the liver, ligation or flashing of the bile ducts is performed.

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