Surgical paper VII
Hepatobiliary basin-type biliary-enteric drainage
A Case Report
A 46-year-old male seaman initially underwent cholecystectomy and common bile duct stone extraction in 1973 for cholecystitis and cholelithiasis. Three months post-discharge, he experienced recurrent episodes of biliary tract infection, characterized by abdominal colic, jaundice, fever, and fatigue, persisting for three years. In 1976, symptomatic relief was achieved through the expulsion of two biliary stones via Chinese herbal medicine. Subsequent B-scan ultrasonography in June and December of 1990 identified choledocholithiasis with a 1.9cm diameter stone. Further imaging in October 1991 confirmed extrahepatic choledocholithiasis accompanied by common bile duct dilatation (2.2cm) and left intrahepatic cholelithiasis with bile duct dilatation. No signs of infection or jaundice were observed, and liver function tests were within normal limits. No surgical contraindications were identified, and elective surgery involving a high-level biliary tract incision, basin-type biliary-intestinal drainage, and focal hepatectomy was planned.
Surgical Procedures
Under the guidance of continuous epidural anesthesia, an L-shaped incision was initiated below the right costal margin. The xiphoid process was subsequently excised, extending the incision toward the right axillary line. Upon abdominal entry, the common bile duct was isolated from the pre-existing surgical scar, revealing a multitude of cast stones and a "residual gallbladder" that was notably large and stone-filled.
The perihepatic ligaments, including the left and right triangular, falciform, and left coronary ligaments, were then dissected to facilitate the downward mobilization of the liver. Palpation of the left hepatic duct revealed a cluster of stones accompanied by fibrosis in segment III of the left lateral lobe. Additional stones were identified at the hepatic duct confluence.
Continuing the dissection, the extrahepatic bile ducts outside the hepatic hilum were isolated. Incisions were made in the porta hepatis and umbilical plates, with blunt dissection used to reach the left and right primary hepatic ducts. A high-level incision was performed on the common hepatic duct up to its bulging part to extract the gallstones. This was immediately followed by a hepatectomy of segment III of the left lateral lobe to eradicate the intrahepatic stones and cystic duct dilatation.
The extracted intrahepatic stones were completely removed via the interface between the left hepatic section and the common hepatic duct, followed by a hydrogen peroxide rinse. Hemostasis was achieved via suturing of the left hepatic section. The "small gallbladder" was then excised, and the common bile duct incision was enlarged to facilitate the removal of the lower segment stones. A No. 7 probe was introduced into the duodenum to repair the common bile duct incision.
Subsequently, the common hepatic duct and primary left and right hepatic ducts were exposed, revealing the openings of the secondary hepatic ducts and caudal lobe bile duct. Stone removal and rinsing were performed following ductal dilatation. The basin's rim was meticulously trimmed to maintain a 2mm edge for optimal anastomosis, with a basin diameter of 3.5cm. Finally, hemostatic suspension was applied.
A segment of the jejunum was transected 15cm distal to its origin. The distal jejuno-colonic segment was then elevated anteriorly and anastomosed to the hepatobiliary basin in an end-to-side fashion, employing a layer of mucosal eversion. Upon inspection, no leaks were identified. Subsequently, an anastomosis was performed between the proximal jejunum and the biliary-enteric loop, 40cm distal to the initial anastomosis.
For drainage, a dual cannula system was employed to establish negative pressure drainage beneath the porta hepatis and the hepatobiliary basin. The intraoperative blood loss was recorded at 300ml, and a blood transfusion of 600ml was administered to maintain hemodynamic stability.
Postoperative Course
Hemostatic triple therapy was administered for three days postoperatively, alongside a gold-standard antimicrobial regimen consisting of gentamicin, ampicillin, and metronidazole. The patient's postoperative body temperature plateaued around 38°C for a duration of two weeks. Bloody abdominal exudate was observed for three days but showed no signs of bile leakage. Drainage tubes were safely removed on the 9th postoperative day, with no ensuing abdominal or incisional infections or jaundice. The patient was declared fit and discharged after three weeks.
A 5-month follow-up indicated no episodes of biliary reflux infection or abdominal symptoms. Digestive functions were observed to be normal, and a subsequent B-scan ultrasonography revealed no residual intrahepatic or extrahepatic calculi.
Discussion
There is currently no standardized surgical approach for treating intrahepatic and extrahepatic bile duct stones. Conventional extrahepatic bile duct surgeries often fail to entirely remove stones, alleviate hepatobiliary strictures, or establish smooth drainage, leading to recurrent symptoms. This often necessitates multiple surgeries and may result in acute obstructive suppurative cholangitis (AOSC) and biliary sepsis, both associated with high mortality rates [1]. In recent years, however, many scholars have advocated for extending surgical interventions into the liver itself, enabling comprehensive stone removal and subsequently improving treatment outcomes [2]. Although these procedures are more invasive, when executed with meticulous surgical techniques and well-planned pre- and post-operative care, they yield satisfactory results.
Primary hepatic ducts (Grade I) can be safely dissected beyond the liver parenchyma, thus facilitating the treatment of secondary hepatic duct (Grade II) stones and strictures. If the quadrate lobe is hypertrophic, some surgeons recommend local resection to improve surgical field visibility and ensure precise choledocho-intestinal anastomosis, thereby enhancing the procedure's safety. However, with adept dissection techniques, the liver can be mobilized and manipulated without necessitating quadrate lobe resection. Our case demonstrated that anastomosis could be conveniently performed without resecting the quadrate lobe.
For diverse intrahepatic stone locations, specific treatments were applied in each case. Superficial liver stones were excised through liver parenchymal incisions followed by hepatic repair. Segmental resections were performed for stones confined to specific lobes accompanied by proximal bile duct dilation. For cast stones, direct incisions were made according to the liver entry route, followed by bile duct repair or T-tube and U-tube drainage. For localized liver stones, "sculptural" hepatectomy was executed to avoid resection of healthy liver tissue. It is crucial to preserve the liver's blood supply and bile drainage routes while employing a combination of surgical techniques.
References
-
Huang Zhiqiang. "10-Year Progress in Surgical Treatment of Hepatolithiasis." Journal of Practical Surgery, 1991; 8.9: 447.
-
Wu, J. et al. "Hepatobiliary Basin-Type Enterohepatic Drainage: An Analysis of 209 Cases." Chinese Journal of Surgery, 1989; 27: 130.
-
Wang Zhesheng, et al. "Treatment of Intrahepatic Biliary Stricture Accompanied by Calculi Using Tongue Resection at the Hepatic Hilus: A Report of 56 Cases." Journal of Practical Surgery, 1991; 8.9494
This article was originally published in Transportation Medicine 1993. 7:91 Changhang Hospital, Li Mingjie, Yang Zonghua Shi Lianghui
from 肝胆管盆式胆肠内引流术一例
