SU940748A1

SU940748A1 - Method of outer draining of extrahepatic bile ducts

Info

Publication number: SU940748A1
Application number: SU802923624A
Authority: SU
Inventors: Кирилл Дмитриевич Тоскин; Виктор Николаевич Старосек; Александр Ефремович Гринческу
Original assignee: Toskin Kirill D; Starosek Viktor N; Grinchesku Aleksandr E
Priority date: 1980-05-13
Filing date: 1980-05-13
Publication date: 1982-07-07

Description

Изобретение относится к медицине, а именно к хирургии печени и желчных путей.The invention relates to medicine, namely to surgery of the liver and biliary tract.

Известен способ наружного дренирования внепеченочных желчных протоков путем введения дренажной трубки в общий желчный проток и выведения ее конца на переднюю брюшную стенку [1].A known method of external drainage of extrahepatic bile ducts by introducing a drainage tube into the common bile duct and removing its end to the anterior abdominal wall [1].

Недостатком способа является отсутствие герметичности в месте выхода щренажнэй трубки из паренхимы печени или желчного потока, что приводит к подтеканию желчи в свободную брюшную полость и развитию перитонита.The disadvantage of this method is the lack of tightness at the exit site of the schrenosus tube from the liver parenchyma or bile flow, which leads to leakage of bile into the free abdominal cavity and the development of peritonitis.

Целью изобретения является предупреждение подтекания желчи в свободную брюшную полость.The aim of the invention is to prevent leakage of bile into the free abdominal cavity.

Поставленная цель достигается тем, что по предложенному способу наружного дренирования внепеченочных желчных протоков путем введения дренажной трубки в общий желчный проток и выведения ее конца на переднюю брюшную стенку дренажную трубку после ее проведения через общий желчный проток проводят через левый печеночный проток, далее через проток левого латерального сектора и внутри круглой связки печени.This goal is achieved by the fact that according to the proposed method of external drainage of the extrahepatic bile ducts by introducing a drainage tube into the common bile duct and removing its end to the anterior abdominal wall, the drainage tube after it is passed through the common bile duct through the left hepatic duct, then through the left lateral duct sectors and inside the round ligament of the liver.

Способ осуществляют следующим образом.The method is as follows.

Через разрез общего желчного протока в левый печеночный проток и далее до ощущения препятствия проводят металлический дугообразный проводник с поли5 хлорвиниловой трубкой на дистальном конце (по типу «иголки с ниткой»). На уровне левой сагиттальной борозды печени, перфорируя стенку протока левого латерального сектора, проводник и дренажную 1° трубу проводят в толще круглой связки печени (не выходя за ее брюшинный покров), т. е. внебрюшинно. Круглую связку печени отсекают от пупочного кольца и вместе с дренажной трубкой, проходящей в ее тол15 щине, через добавочный разрез передней брюшной стенки на уровне нижней поверхности печени, выводят и фиксируют послойно к апоневрозу и коже. На дефект общего желчного протока накладывают ²⁰ глухой шов или формируют билиодигестивный анастомоз. Затем операционную рану послойно ушивают.Through the incision of the common bile duct into the left hepatic duct and further to the sensation of an obstacle, a metal arc-shaped conductor with a poly5 vinyl chloride tube at the distal end is carried out (as a “needle with a thread”). At the level of the left sagittal groove of the liver, perforating the duct wall of the left lateral sector, the conductor and the 1 ° drainage tube are carried out in the thickness of the round ligament of the liver (without leaving its peritoneal cover), i.e., extraperitoneally. The round ligament of the liver is cut off from the umbilical ring and, together with the drainage tube passing in its thickness, through an additional incision of the anterior abdominal wall at the level of the lower surface of the liver, is removed and fixed in layers to the aponeurosis and skin. On the defect of the common bile duct impose ²⁰ blind suture or form biliodigestive anastomosis. Then the surgical wound is sutured in layers.

Пример 1. Больная Б., 56 лет, поступила в хирургическое отделение с выра25 женной желтухой. Четыре года назад в одной из больниц области во время операции по поводу дивертикула двенадцатиперстной кишки был случайно пересечен общий желчный проток, и наложен холеци30 стоеюноанастомоз. В последующем у боль940748 мой неоднократно возникали приступы ознобов с выраженной желтухой. Два месяца назад после очередного приступа появилась стойкая желтуха. Консервативная терапия эффекта не дала. Больная переве- ⁵дена в клинику и оперирована, во время операции обнаружен полный стеноз холецистоеюноанастомоза. Выделен общий печеночный проток на расстоянии 4 см., диаметр его 3,5 см. Решено наложить гепати- 10 кодуоденоанастомоз, из-за технических сложностей (рубцовая деформация тканей) с целью декомпрессии в области анастомоза произведено дренирование общего печеночного протока через круглую связку 15 печени. Наложен гепатикодуоденоанастомоз однорядным лавсановым швом. Послеоперационный период протекал гладко. На восьмой день произведена чреззондовая холангиография, пассаж контраста в две- 20 надцатиперстную кишку· хороший. Дренаж из желчных путей удален на девятый день. Выделения желчи в последующем через круглую связку печени не было.Example 1. Patient B., 56 years old, was admitted to the surgical department with severe jaundice. Four years ago, during a surgery for a duodenal diverticulum in one of the region’s hospitals, the common bile duct was accidentally crossed and a cholecyst30 stojunoanastomosis was applied. Subsequently, my pain 940748 repeatedly had bouts of chills with severe jaundice. Two months ago, after another attack, persistent jaundice appeared. Conservative therapy did not work. Patient pereve- ⁵ dena at the clinic and is operated during the operation revealed a complete stenosis holetsistoeyunoanastomoza. The common hepatic duct was isolated at a distance of 4 cm, its diameter was 3.5 cm. It was decided to apply hepatitis 10 coduodenoanastomosis, due to technical difficulties (cicatricial deformation of tissues), the common hepatic duct was drained through the round ligament 15 of the liver to decompress the anastomosis . Hepatic coduodenoanastomosis is applied with a single-row lavsan suture. The postoperative period was uneventful. On the eighth day, trans-probe cholangiography was performed; the passage of contrast in the two to twenty duodenum was good. Bile duct drainage removed on the ninth day. There was no secretion of bile subsequently through the round ligament of the liver.

Пример 2. Больная Н., 76 лет посту- 25 пила в хирургическое отделение с диагнозом: острый холецистит, перитонит. В связи с выраженностью перитонеальных явлений после проведенной предоперационной подготовки '— операция. Во время операции ³⁰обнаружен острый флегмонозный холецистит, местный перитонит. Общий желчный проток расширен до 2 см. При холедохотомии в протоке обнаружен гной, терминальный отдел холедоха проходим. Произведе- 35 на холецистэктомия, общий желчный проток дренирован через круглую связку печени, наложен глухой шов холедоха. Подпеченочное пространство дренировано. Послеоперационный период протекал гладко. ⁴⁰Первые трое суток по дренажу оттекала мутная с хлопьями желчь, в последующем она стала светлее, прозрачнее. На седьмые сутки произведена смена дренажа общего желчного протока по методике Сельлингера для чрежкожной катетеризации сосудов. Сделана контрольная чрездренажная холангиография — дренажная трубка располагается точно в общем желчном протоке, пассаж контраста в двенадцатиперстную кишку свободный.Example 2. Patient N., aged 76, was admitted to the surgical department with a diagnosis of acute cholecystitis, peritonitis. In connection with the severity of peritoneal phenomena after the preoperative preparation, '- operation. During operation ³⁰ , acute phlegmonous cholecystitis, local peritonitis was detected. The common bile duct expanded to 2 cm. With choledochotomy, pus was found in the duct, the terminal part of the common bile duct is passable. 35 was performed for cholecystectomy, the common bile duct was drained through the round ligament of the liver, and a blind suture of the common bile duct was imposed. The subhepatic space is drained. The postoperative period was uneventful. ^{40 For the} first three days, bile, cloudy with flakes, flowed out through drainage, later it became lighter, more transparent. On the seventh day, the drainage of the common bile duct was changed according to the Sellinger technique for percutaneous catheterization of blood vessels. A control over-drainage cholangiography was made - the drainage tube is located exactly in the common bile duct, the passage of contrast into the duodenum is free.

Дренаж убран на 10-й день, выделения желчи через круглую связку в последующем не отмечалось.The drainage was removed on the 10th day, bile secretion through a round ligament was not subsequently observed.

Преимуществом данного способа является его универсальность, т. е. он может быть применен в диапазоне от обычного дренирования холедоха после его вскрытия с последующим наложением глухого шва до дренирования сменными дренажами в течение длительного времени с целью формирования сложного биолиодигестивного анастомоза. Он может быть применен также для разгрузки желчных путей при сфинктеротомии, при сшивании поврежденного тепатохоледоха и т. д. Способ менее травматичен: при его применении не повреждаются крупные печеночные сосуды и желчные ходы, так как проток левого латерального сектора, через который дренаж непосредственно выходит в круглую связку на .уровне левой сагитальной борозды печени, располагается выше и несколько впереди от левой воротной вены. При данном способе дренирования исключается подтекание желчи в свободную брюшную полость, так как дренажная трубка проходит через круглую связку печени внебрюшинно.The advantage of this method is its versatility, i.e., it can be used in the range from conventional drainage of the common bile duct after opening it with the subsequent application of a blind suture to drainage with removable drainages for a long time in order to form a complex bio-digestive anastomosis. It can also be used to unload the bile ducts during sphincterotomy, when stitching damaged hematopoiesis, etc. The method is less traumatic: when it is used, large hepatic vessels and bile ducts are not damaged, since the duct of the left lateral sector through which the drainage goes directly to a round ligament at the level of the left sagittal groove of the liver, is located above and somewhat in front of the left portal vein. With this method of drainage, bile leakage into the free abdominal cavity is excluded, since the drainage tube passes through the round ligament of the liver extraperitoneally.

Claims

Tyuis repeatedly had bouts of chills with severe jaundice. Two months ago, after another attack, a jaundice persisted. Conservative therapy did not give effect. The patient was transferred to the clinic and operated on, during the operation a complete stenosis of the cholera) 1, istojunoanastomosis was found. The common hepatic duct at a distance of 4 cm was selected, its diameter was 3.5 cm. It was decided to impose hepaticoduodenal anastomosis, due to technical difficulties (scar tissue deformation) with the aim of decompression in the anastomotic area, the common hepatic duct was drained through the circular linkage of the liver. Imposed hepatocoduodenostomy with single side lavsan suture. The postoperative period was uneventful. On the eighth day, transband cholangiography was performed; contrast passage into the duodenal lobe was good. Drainage from the biliary tract was removed on the ninth day. There was no bile flow through the circular linkage of the liver. Example

2. Ill N., 76 years old, was admitted to the surgical department with a diagnosis of acute cholecystitis, peritonitis. In connection with the severity of peritoneal manifestations after preoperative preparation, this is an operation. During the operation, acute phlegmonous cholecystitis, local peritonitis was detected. The common bile duct is expanded to 2 cm. When choledochotomy, pus is found in the duct, we pass the terminal section of the choledochus. The cholecystectomil was produced, the common bile duct was drained through the circular junction of the liver, and a deaf suture of the common bile duct was applied. Subhepatic space drained. The postoperative period was uneventful. For the first three days, the drainage flowed out with muddy flakes of bile, later it became lighter, more transparent. On the seventh day, the common bile duct was changed according to the Sellinger technique for transcutaneous catheterization of the vessels. Control relief cholangiography was done - the drainage tube is located exactly in the common bile duct, the passage of contrast to the duodenal lobe is free. Drainage was removed on the 10th day, bile flow through the round link was not observed later. The advantage of this method is its versatility, i.e. it can be applied in the range from the usual choledoch drainage after it has been opened, followed by the laying of a hollow groove to the drainage with interchangeable drainage for a long time in order to form a complex biolyodigestive anastomosis. It can also be used for unloading of the biliary tract during sphincterotomy, during cleavage of injured tepatochledochus, etc. The method is less traumatic: it does not damage large hepatic vessels and bile ducts, because the duct of the left lateral sector through which the drainage directly goes into round St. W | Ku at the level of the left sagittal furrow of the liver, located above and slightly ahead of the left portal vein. With this method of drainage, the flow of bile into the free haul cavity is eliminated, since the drainage tube passes through the circular ligament of the liver extraperitoneally. Claims of the method of external drainage of the extrahepatic bile ducts by inserting a drainage tube into the common bile duct and placing its end on the anterior stem wall, characterized in that, in order to prevent bile leakage into the free (fraying cavity, drainage tube after it passes through the common bile duct) conducted through the left hepatic duct, then through the duct of the left lateral sector and inside the circular ligament of the liver Source of information taken into account during the examination: 1. J. Surgeons, 1978, № 10, pp. 131-136, O. B. Milonov and Yu. V. Ostrozhnikov, External transhepatic drainage of the hepatic and bile ducts.