胆总管探查步骤

胆总管探查步骤

1、Exposure of the CBD by packs and retractors.

2、A, The gallbladder has been removed. The dotted line indicates the incision in the retroperitoneum to allow mobilization of the duodenum by the Kocher maneuver (B).

3、The CBD is opened just above the duodenum leaving room for a choledochoduodenostomy if this is found to be necessary.

4、Two fine stay sutures of 4-0 polydioxanone suture (PDS) or 4-0 polyglactin 910 (Vicryl) are used to lift and render the CBD tense for an incision about 1 to 2 cm long, depending on the size of the duct and the size of the stones. If the CBD is not made tense, damage can be done to the posterior wall, or an irregular incision can be made.

5、A Fogarty catheter is fed into the duct with forceps using the right hand. The operator’s left hand grasps the mobilized duodenum and allows palpation of the passage of the catheter and of any stones within the intrapancreatic portion of the CBD.

6、A, The Fogarty catheter is attached to a syringe, and the balloon is inflated in the duodenum. B, The Fogarty catheter is retracted with the balloon against the papilla. C and D, The balloon is deflated and gently withdrawn until it slips through the papilla; the balloon is reinflated.

7、A, The balloon is withdrawn gently, revealing the stone. B, Long forceps can be used to obstruct the common hepatic duct to prevent the stone from slipping upward.

8、A, The T-tube is modified by shortening the limbs to prevent proximal obstruction and distal entry into the duodenum. B, A T-tube is modified by removing half the diameter to prevent obstruction and enable easy removal.

9、The T-tube is introduced by Desjardin’s forceps.

10、The choledochotomy closure using interrupted 4-0 Vicryl 4-0 polydioxanone absorbable suture (PDS) or 4-0 polyglactin absorbable suture (Vicryl) is begun above with the T-tube emerging at the lower end of the repair.

11、The T-tube should be brought out lateral to the wound. A closed-suction drain should be placed in the hepatorenal space beneath the liver.

1.充分暴露手术野

2. Kocher方法游离十二指肠及胰头，以便用左手可以扪查胆总管的胰腺段

3. 4－0可吸收线或3－0丝线缝合胆总管悬吊。（穿刺证实后）

4. 切开胆总管，长度约1cm－2cm。

5. 用大小合适的Forgarty导管置入胆总管。或用导尿官冲洗。现在国外多数主张不用金属探条、刮匙等。可用胆道镜取石网或取石篮取石。多主张用取栓导管（球囊导管）。现在ERCP多用球囊导管。

6. 球囊导管取石示意图

7. 球囊导管取石示意图

如有条件，取石后最好用胆道镜全面检查。如无胆道镜，则行T管造影。如无造影条件，那就靠自己的技术和经验了，毕竟我国各地医疗条件差异很多，广大基层医院不一定都有胆道镜和术中造影条件，胆总管结石患者基层很多，基层医生也要开展手术。

但是，预防胆总管下端损伤及防止残留结石的最好方法是行十二指肠胰头充分游离、翻起，使左手能容易的扪摸胆总管的十二指肠后段、胰腺段、十二指肠内段。同时如果用取石钳或探条，左手也能扪摸、引导。防止出现十二指肠破裂或假道形成，出现严重并发症。同时也容易扪摸胆总管下端是否有结石。