Hepatorenal artery anastomosis
The ratio of portal vein to hepatic artery to the liver is 80% and 20%. About 50% of the oxygen supply to the liver comes from the hepatic artery. After the common hepatic artery is issued by the celiac trunk, it walks along the upper edge of the pancreas, separates the stomach and duodenal artery, and then divides it into the left and right portal veins, and then divides the left and right hepatic arteries into the liver and biliary tract. system. 12% of the right hepatic artery originates from the superior mesenteric artery. The hepatic artery has a blood flow of 300 ml per minute and a perfusion pressure of 11.9 kPa, which can meet the physiological needs of the renal blood circulation (Fig. 220.127.116.11-1). The hepatic artery is a non-terminal artery, which has a rich collateral circulation. A collateral circulation can be established 10 hours after hepatic artery ligation. The experiment blocked the hepatic artery and the liver function was not affected (Mays, Wheeler), providing an anatomical basis for the operation of hepatic-renal artery anastomosis. Since Libertino performed 3 cases of hepatic-renal artery anastomosis in the treatment of right renal artery stenosis in 1976, several medical centers in the United States have performed dozens of cases, and all have received good results, thus becoming the right renal artery. The preferred procedure for stenosis surgery.Treatment of diseases: renal artery stenosis Indication
Where the right renal artery stenosis, the distal segment of the trunk is normal, transabdominal aorta-peritoneal angiography, hepatic artery imaging shows normal, narrow renal artery disease can not be cured with other more effective methods, you can choose liver and kidney arterial anastomosis Surgery. If used for pediatric right renal artery stenosis, the success rate is high and the effect is good.Preoperative preparation
2 weeks before surgery should be given to the general antihypertensive drugs, in order to avoid a sudden drop in blood pressure after surgery, resulting in extremely severe blood perfusion of vital organs and crisis. If the blood pressure is particularly high, and the diastolic blood pressure is as high as 16 to 18.7 kPa (120 to 140 mmHg), a short-acting antihypertensive agent such as -methyldopa (alphamethyldopa) can still be applied, which can appropriately delay the timing of surgery. The experience can last until the preoperative. If surgery is urgently needed and hypertension cannot be controlled, intravenous sodium nitroprusside can be used to meet the conditions required for surgery.
The blood volume of such patients is reduced by 500-1500 ml compared with normal, and should be supplemented before surgery to avoid shock caused by postoperative blood pressure drop. Hypokalemia due to secondary aldosteronism and long-term diuretic therapy should be corrected before surgery to reduce the sensitivity of anesthesia and surgery to myocardial irritation.
Any infection of the urinary system should be controlled and cleared before surgery. Pyelonephritis is given effective anti-infective treatment 3 weeks before surgery. If azotemia is present, it should be properly corrected. For the stenosis caused by aortitis, comprehensive treatment is needed. After the active period, the local lesions are stable, and surgery can be performed. In order to protect the renal parenchyma that has been damaged by ischemia, it is in the best functional state. In addition to avoiding the use of nephrotoxic drugs, mannitol or furosemide can be administered shortly before surgery. Systemic heparin therapy should also be initiated before surgery to prevent postoperative thrombosis. The above two treatments also need to be repeated before clamping the renal artery and need to be maintained until the end of the operation.
Intraoperative central venous pressure monitoring should be done before the catheter and device. The fluids and related instruments required for cold perfusion of the renal arteries that may be performed during surgery should be prepared.Surgical procedure
After the abdominal incision enters the abdominal cavity, the hepatic artery and its branches are exposed in the right upper abdomen to explore the extent of the right renal artery lesion. After the decision to use hepatic and renal artery anastomosis, according to the anatomy of the artery, the following procedures can be used:
1. The common hepatic artery was cut at the distal side of the stomach and the duodenal artery, and the distal end was ligated, and the proximal end was anastomosis with the distal end of the severed renal artery.
2. Cut the stomach and duodenal artery, and the proximal end is end-to-end with the distal end of the renal artery, or the end-to-side anastomosis.
3. Autologous saphenous vein grafting between the common hepatic artery and the renal artery.
4. The left and right branches of the hepatic artery are cut off respectively, and then the branches of the renal artery are respectively end-to-end anastomosis. If the branch is too short, the autologous vascular graft can be bridged to solve the problem of complete obstruction of the renal artery trunk.
Renal artery reconstructed by the above 2, 3 surgery can still have low renal perfusion pressure and ischemia, and it is not clinically useful.