Surgical procedures for PTC

1. Transaxillary intercostal puncture

⑴ Puncture approach, generally using the right midaxillary line 8 ~ 9 ribs or 9 ~ 10 intercostal space. When possible, it is better to observe the variation of liver directly under X-ray monitoring, and adjust the height, direction and depth of puncture point.

⑵ Disinfection, covering, puncture point local anesthesia.

⑶ According to the selected puncture point into the needle, horizontal direction, the tip of the needle pointing to the xiphoid tip.

Generally, the needle is about 8 ~ 13cm, and the bile duct is thicker. When the needle is inserted into the bile duct, there is a sense of breakthrough. At this time, pull out the needle core, replace the syringe, slowly withdraw the needle, and suction at the same time. If bile is extracted, the withdrawal will stop, indicating that the needle tip has been in the bile duct. If bile is not withdrawn and the needle is withdrawn to 1/2 of the needle path, the puncture is considered to have failed. The needle should be withdrawn to the subcutaneous layer and the direction should be slightly changed before puncture. Continue 4 ~ 5 times, still did not extract bile should stop the operation, so as not to damage too much liver tissue.

⑸ can also be used under the method, into the needle to the appropriate depth, first inject a small amount of contrast agent, in the X-ray fluorescent screen display to determine the position of the needle. If the needle strays into the blood vessel, the contrast agent will be diluted and quickly flow away; If the needle is in the liver parenchyma, the contrast agent will remain motionless; If contrast agent enters hepatobiliary tube, visible contrast agent flows slowly to hepatic hilar.

After successful puncture, the needle was fixed, the syringe with plastic tube was connected, and part of the bile was extracted and sent for bacterial culture. Then slowly inject 20ml of warm 30%-50% meglumine. When the patient feels slight swelling of the liver area, the injection should be stopped and radiography should be performed. If the bile duct is highly dilated, the dose of contrast agent can be increased appropriately.

⑺ after taking a piece, try to suck out the bile mixed with contrast agent, so as not to leak bile. If the photo is satisfactory, the inspection can be finished. If you are not satisfied, you can inject contrast medium again to take pictures.

2. The puncture site of the transabdominal puncture method was selected under the right costal margin, the puncture point was 2cm below the xiphoid process, 2cm to the right of the midabdominal line, and the puncture point was at a 40° Angle with the mesa, and the puncture point was directly stabbed to the liver. The appropriate puncture needle should be 12cm long. This method is applicable to patients with liver enlargement.

3. Extraperitoneal puncture is performed through the bare area behind the liver. Because this bare area remains constant even when the liver is enlarged; There is no injury to vital organs, biliary peritonitis or intraperitoneal hemorrhage. Right phrenic nerve block was performed before angiography. Methods: the anterior margin of sternocleidomastoid muscle was 2 ~ 3cm above the right clavicle, and the range of motion was decreased with 2% increase, indicating that phrenic nerve block was effective.

Then the patient was placed in the prone position, and conventional local anesthesia was performed at the upper edge of the right 11 ribs, 6-7cm from the posterior median line. The liver was punctured with a 15cm-long puncture needle, with the needle slightly pointing inward. When the needle penetrated 10-12cm, the needle was withdrawn by the above method, and bile was extracted to indicate successful puncture [FIG. 1].

The injection of contrast medium and the procedure of film taking were the same as before.

This approach is far less successful than the transaxillary approach.

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