Emergency laparotomy cholecystectomy complications of bile leakage
Author: Liu Xin-Wen Xiu-Ling Li Wen Xian so
【Abstract】 Objective To investigate the method of emergency open cholecystectomy bile leakage caused by the causes and preventive measures. Methods A retrospective analysis of our hospital from December 1998 to December 2008 540 cases of emergency, opening up the Law of bile leakage after cholecystectomy clinical data. Results The proportion of patients with bile leakage occurred 1.85%, 8 cases of postoperative
intraperitoneal drainage, 2 cases of biliary-enteric Roux-en-Y type anastomosis, are
cured. Conclusion vagus extrahepatic bile duct and bile duct injury is caused by acute bile leakage after cholecystectomy the main reason. The establishment of patency of the peritoneal drainage, or biliary-enteric anastomosis is the treatment and prevention of
bile leakage key.
Key words open method of emergency cholecystectomy bile leakage prevention measures
Biliary tract surgery bile leakage is due to negligence or improper handling, resulting in leakage of bile into the bile duct injury in the abdominal cavity, the formation of bile peritonitis, localized abscesses and other complications of the negative consequences
, is a biliary tract surgery in the more serious complications, in particular, France in the emergency open cholecystectomy, the gallbladder, bile duct anatomy is unclear or show variations, combined with surgery were more likely caused by technical factors,
the incidence of bile leakage. Our hospital from December 1998 to December 2008 emergency open cholecystectomy in 540 cases of France, bile leakage occurred in 10 cases, the incidence of 1.85%. Is combined with clinical practice, on the reduction of
bile leakage occurred, to improve surgical safety were studied.
A clinical data
Bile leakage occurred in this group 10 cases, including 7 males and 3 females, aged 45 to 78 years (mean 62 years). Were 10 cases of acute cholecystitis, of which 6 cases of
gallstones. Pathologically confirmed eight cases of suppurative cholecystitis, 2 cases of gangrenous cholecystitis. 10 cases of bile leakage in 2 cases of intraoperative bile duct transection injuries, 8 cases of bile duct injury to the vagus.
2 treatment and results
Postoperative bile leakage occurred in 10 cases of liver were placed under the abdominal drainage tube, in which two cases of postoperative abdominal drainage tube from the day of golden-yellow bile flow of about 150ml and 200ml or so, after the first
two days were led to about 600ml, 800ml or so, by Caesarean section transection of common bile duct exploration confirmed, rows of common bile duct - jejunal Roux-en-
Y anastomosis, patients discharged; the other eight cases after the first two days to five
days out of yellow bile peritoneal drainage tube-like liquid, daily drainage is about 100
~ 200ml or so, because of emergency surgery, intraoperative see heavy inflammation of the gallbladder bed to tackle the problem, consider the aberrant bile duct injury, so
line conservative treatment to maintain drainage tube patency, persistent drainage 7 ~ 10d after the extubation, patients discharged . Reposted elsewhere in the paper for free download http://
3.1 The cause of bile leakage caused by pathological anatomic abnormalities of extrahepatic bile duct injury and bile duct injury in the gallbladder bed vagus is emergency cholecystectomy bile leakage caused by the main reason. Emergency cholecystectomy, mostly suppurative cholecystitis, due to inflammatory edema, hyperemia, fragile, and the relationship between the gallbladder triangle anatomy is unclear, or long-term repeated episodes of chronic inflammation, so the gallbladder wall thickening, hardening, gallbladder closed triangle can not be free, and even the gallbladder variation in the structure of distortions in the surrounding tissues and organs to form dense adhesions; cystic duct stones when the stone can be partially incarcerated into the hepatic duct and gallbladder neck to form a large cavity of the Ministry of migration has been mistaken for the gallbladder, the bile duct was mistaken for the cystic duct ligation cut off ; In addition, the cystic duct is too long or too short or import parts of mutations can be caused by extrahepatic bile duct injury caused by bile leakage. The group 2 patients had common bile duct injuries are inflammatory adhesion cross-sectional weight, gallstones, gallbladder tension of large, neck of gallbladder stones into the hepatic duct and cystic duct to form large cysts transitional Department, is considered as the gallbladder and the cystic duct to common bile duct for distal common bile duct ligation, the proximal cut off, due to inflammatory edema adhesion weight, surgery is not found in bile spill, postoperative edema occurs when bile leakage, the latter due to outflow of gold instead of yellow bile yellow bile-like liquid, for 2 second laparotomy was found for the common bile duct injury, and can not be OK and the line of common bile duct bile duct jejunum
anastomosis between the Roux-en-Y anastomosis and cure. In addition, lack of
knowledge of the vagus bile duct, caused by the injury caused by delayed bile leakage can not be ignored . Common bile duct due to the vagus are directly connected to the
gallbladder and intrahepatic bile duct pipes, its biliary openings were often located in the lower part of the body of the gallbladder, the liver often import right lobe posterior segment, diameter of 1 ~ 2mm, occurrence rate of 5% ~ 30% , especially the smaller vagus bile duct tape may be cut off and fiber adhesion caused by injury or electric coagulation easily found on the stump has not dealt with, leading to bile leakage. 8 cases in this group to consider aberrant bile duct injury caused by bile leakage. Because of postoperative bile drainage are pale yellow liquid, rather than the whole yellow bile, coupled with intraoperative see suppuration or gangrene of gallbladder to deal with when the fear caused by the gallbladder bed bleeding on the gallbladder bed did not complete coagulation, while the gel-foam packing oppression caused by intraoperative
bile duct injury vagal failed to find that it is felt that more in line with the vagus bile duct injury caused by bile leakage. Place because of intraoperative peritoneal drainage, maintain drainage tube patency, from 2 to 5 days after operation, bile leakage was found after a day, are pale yellow bile liquid, and gradually reduced, continuous drainage 7 ~ 10d about drainage tube without liquid leads to, B ultrasonic examination
without the liver under the fluid and extubation, patients discharged. In addition, scholars believe that: patients with mutations in the cystic artery or lead to bleeding; blind clamp electrocoagulation and ligation is also easy to accidental injury caused by bile duct or hepatic duct bile leakage; intraoperative perforation secondary to thermal burns, and common bile duct bile duct wall lower segment plexus damage caused by ischemia and perforation of common bile duct bile leakage, also can occur.
3.2 The prevention of bile leakage control Calot triangle aberrant bile duct anatomy and the existence parts operation to follow the formal steps in the prevention of bile leakage, etc. The key . Calot triangle is divided into cystic neck-centric security area
and to three converging areas of the danger zone as the center , only in safe areas to isolate the cystic duct anatomy, and never in the danger zone anatomy, surgery to the extent possible discern three one ampulla (hepatic duct, common bile duct, cystic duct and gallbladder ampulla) the relationship between pairs of gallbladder Triangle enlarged lymph nodes can be identified as the gallbladder and the cystic duct at the junction of ampulla sign. Lymph nodes along the ampullary and gallbladder should be isolated between the cystic duct 0.3 ~ 0.5cm from the common bile duct ligation of the cystic duct, cutting more reliable security, and thus avoid the common bile duct injury. Surgery on the gallbladder bed after the processing of routine flushing the gallbladder bed with a dry gauze and press to see whether the bile contamination, especially for cord membranes by a careful view, difficult to determine the right moment the vagus
bile duct through cystic duct stump with intubation injecting methylene blue to help find a bile leak, timely electrocoagulation or ligation. Some people think that electrocoagulation method is not reliable, some patients may still eschar caused by delayed postoperative bile leakage, and therefore suspicious persons should be routinely placed drainage tube, and the local application of fibrin glue. A small leak through the drainage of bile and self-healing, for obvious leaks were extrahepatic bile
duct injury should be considered for those who appear to be timely laparotomy peritonitis adequate drainage, as far as possible repair or bypass of biliary bile, especially for postoperative abdominal drainage should be pay more attention, it may prevent the recurrence of the damage caused by surgery .
In short, the surgeon should correctly treat all cases of cholecystectomy cases, especially for emergency gallbladder surgery, but surgery should be carefully observe the basic operation of the formal steps, are familiar with anatomic abnormalities and
pathological importance of the gallbladder bed treatment of bile duct vagus, as well as to maintain a fluid peritoneal drainage, these measures in the prevention and treatment of biliary leakage plays an important role.
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