HOLEDOHOTOMYYa [lat. (ductus) of choledochus a bilious channel + Greek tome a section, a section] — opening of a gleam of the general bilious channel.
For the first time successfully made a choledochotomy in 1889 Mr. Thorn-ston. The same year F. I. Berezkin removed by a choledochotomy a stone from the general bilious channel.
Most often the choledochotomy is carried out for removal of gallstones from extrahepatic channels, for drainage of the general bilious channel at a purulent infection of bilious ways and as the stage of imposing of an anastomosis with bodies went. - kish. a path (a stomach, a duodenum, a jejunum) at the resistant impassability of distal department of the general bilious channel caused by a stone, a stricture, a tumor. Approximately in 1/3 cases the choledochotomy is made during operation of a cholecystectomia for cholelithiasis.
The question of indications to a choledochotomy is not simple as unreasonable opening of the general bilious channel is regarded as a mistake, and failure from it when for this purpose there are bases, is rough omission. Indications to a choledochotomy shall be strictly proved — the decision is made on the basis of a careful research of bilious channels during operation, not only visual and pal-iatorny, but also radiological (a holangiografiya, a telekholangiosko-piya), and also a tool research by means of measurement of diameter of a channel, transillumination, sounding through a vesical channel, etc. (see. Bilious channels, methods of a research).
As the choledochotomy always complicates technology of operation and a current of the postoperative period, diagnostic opening of the general bilious channel shall be minimized. The choledochotomy should be undertaken only after carrying out a comprehensive complex intraoperative investigation if there are suspicions about existence not Vyya in lenny pathological changes of the general bilious channel. According to many surgeons, after implementation in broad surgical practice of a complex intraoperative research of bilious channels the number of diagnostic choledochotomies considerably decreased.
Distinguish a supraduodenalny, retroduodenal and transduodenal choledochotomy. Most often apply a supraduodenalny choledochotomy.
After a laparotomy (see) bare a hepatoduodenal sheaf, on the outer edge the cut from a neck of a gall bladder to a duodenum usually is located the general bilious channel. The peritoneum covering it is cut, in the stupid way divide cellulose and bare a front surface of the general bilious channel. In doubtful cases the channel is punktirut a fine needle; emergence in the syringe of bile or blood indicates accessory of this anatomic education. On a wall of a channel an atraumatic needle impose against each other two thin threads handles, between to-rymi a wall cut in lengthwise direction. The bile which are emitted at the same time, pus, small stones, «putty» are deleted with a suction. The wound of the general bilious channel is expanded by means of scissors (better with angular branches) to 1,5 — 2 cm (depending on width of a channel). At the same time its bottom edge shall be located at distance
about 10 cm from a wall of a duodenum that allows to complete if necessary a choledochotomy choledochoduodenostomy (see). Enter special nippers into a gleam of the general bilious channel with izog-
Fig. The diagrammatic representation of a stage of removal of a stone from the general bilious channel at a supraduodenalny choledochotomy: 1 — the gallstone taken by nippers; 2 — threads of a handle; 3 — the general bilious channel; 4 — a duodenum; <5 — a vesical channel.
nuty branches also take concrements (fig). They are deleted with also special spoons, a suction, the thin tip to-rogo is entered in the distal and proximal directions, washed away a stream of warm isotonic solution of sodium chloride. All these manipulations should be carried out before full removal of all concrements. For the purpose of control of passability of a faterov of a nipple (a big duodenal nipple of a duodenum, T.) use the plastic calibrated probes (see) and a holangiografiya (see). At the driven stones or strictures of terminal department of the general bilious channel undertake a papillosfinkterotomiya (see Faterov of pacifiers) or impose one of a biliodigestivny anastomosis (see. Bilious channels). Cyri ra a duoden to flax yu finish a choledochotomy with sewing up of a wound of a channel tightly, or its drainage — outside or internal (imposing of an anastomosis with bodies of digestive tract). The deaf seam of the general bilious channel is applied at its free passability and lack of a cholangitis, using the noose, P-shaped or continuous sutures put in one or two rows. For the purpose of the prevention in these cases of development of bilious hypertensia (a spasm of a sphincter of Oddi, or a sphincter of an ampoule) and creations of bigger tightness of a seam it is reasonable to carry out in parallel temporary decompressive drainage of the general bilious channel of tons of oil a polyethylene tube through a vesical channel or an additional opening in a wall of the general bilious channel.
At uncertainty in a full removing calculus, not eliminated disturbance of outflow of bile in a duodenum and considerable expansion of the general bilious channel make internal drainage of the last by creation bypass x about l food of X about duodeno anastomosis or a holedokhoyeyunoanastomoz. In need of outside drainage of the general bilious channel (see the Choledochostomy) use tubes from various materials and a different design.
The retroduodenal choledochotomy is applied in need of opening of the general bilious channel behind a duodenum. For this purpose the duodenum will be mobilized on Kokhera (see Papk-reatoduodenektomiya), bare ret-roduodenalny department of the general bilious channel and open a front wall of a channel between two threads handles. At the same time it is necessary to show big care not to injure the back upper pankreatoduodenalny artery or the vein of the same name located in this area and also tissue of a pancreas that is fraught with serious complications.
After removal of a stone from a channel (quite often it presents great difficulties) and control of passability of the general bilious channel (see above) carefully take in a dissect wall of a channel an atraumatic needle. The channel is drained through a section in supraduodenalny department. The abdominal cavity is in addition drained the rubber tube removed through counteropening (see Drainage).
The retroduodenal choledochotomy is technically more difficult, than supraduodenalny and it is much more dangerous because of possibility of considerable bleeding from the large blood vessels located around a channel, and also danger of development of pancreatitis, a pancreatonecrosis, peritonitis and bilious and pancreatic fistula in connection with accidental injury of a pancreas.
Allocation of a retroduodenal part of the general bilious canal becomes even more difficult and dangerous at inflammatory changes of its wall and surrounding fabrics. In this regard in a crust, time resort to this operation extremely seldom, giving p a redpochteniye soup of a raduode-pas of l n oh and to a transduodenal choledochotomy, or imposing of a bypass biliodigestivny anastomosis.
r and week at odsnat t ny holedokhoto -
Mia is made during removal of the gallstones restrained in terminal department of the general bilious channel. It is usually difficult to find them at a palpation therefore for definition of the place of opening of a duodenum (considering variability of an arrangement of the mouth of the general bilious channel) through a supraduodenalny holedokhotomichesky opening enter the thick plastic probe and will see him to the place of obstruction of a channel. The end of the probe which is stuck out up konturirutsya on a front wall of a duodenum, indicating the place where it is necessary to open the last throughout
2 — 2,5 cm. After cultivation of edges of a wound of a wall of a gut the evaginated site of a back wall of a gut with the mouth of the general bilious channel becomes hooks visible, from to-rogo the tip of a stone sometimes acts. For removal it happens to cut enough in the radial direction a regional part of a faterov of a nipple (a transpapillary choledochotomy). If the stone was restrained in an ampoule of the general bilious channel, then over it cut a wall of a gut and a channel (a suprapaiillyarny choledochotomy). After removal of a stone the mucous membrane of a gut and general bilious channel is sewed (see. Intestinal seam). The opening in a front wall of a duodenum is taken in two-row seams. The general bilious channel is drained more often through a supra-duodenal holedokhostoma or taken in tightly with introduction of a drainage through a vesical channel (see above). The abdominal cavity is drained a rubber tube.
See also Bilious channels. Bibliography: Berezkin F. I. To hi
rurgiya of bilious ways, Surgery, t. 6, No. 31, page 224, 1899; Ishchenko I. N. Operations on the bilious ways and a liver, Kiev, 1960; Matyushin I. F. Practical guidance on operational surgery, Gorky, 1979; The M and l.o is new O.B. and T and m about sh and A. D N. A complex research during operations on the bilious ways, M., 1981; Operational surgery, under the editorship of I. Littmann, the lane with Wenger., page 606, Budapest, 1982; About the h to and A. D N. Cholelithiasis, cholecystitis and their surgical treatment, M., 1949;
Smirnov E. V. Surgeries on the bilious ways, JI., 1974.
O. B. Milonov.