2026年 · 第41卷第01期

A 43-year-old male suffered from chest pain on the right side for half a year, which was aggravated for more than half a month. There was no history of surgery or trauma. Physical examination showed that the thorax was symmetrical and the breathing sound of the right lower lung was weakened. Chest CT showed a right diaphragmatic hernia, and the contents of the hernia were liver, gallbladder and colon (Figure 1). A 1 cm incision on the upper edge of the umbilicus was taken, a pneumoperitoneum was established and a laparoscope was placed. Exploration showed a left diaphragmatic hernia, and part of the liver, gallbladder and colon herniated into the chest cavity (Figure 2). Part of the intestinal tube was pulled back to the abdominal cavity from the hernia sac of diaphragm hernia, and the diameter of the hernia sac was about 10 cm. After the intestinal tube was returned, the anatomical structure of the liver was abnormal. The part of the right liver that was compressed by the hernia ring was located on the inside of the hernia ring and was tightly adhered to the hernia sac of diaphragm hernia. The surface of this part of the liver was atrophied, showing cystic change. The atrophied part of the liver in the hernia sac was ligated with liver needle and then resected, and the section was fully hemostatic. Suture the V-lock thread to reduce the hernia ring, and place a PFM patch, size 15 cm ×15 cm. The bottom of the patch and the retroperitoneum were continuously sutured with a 2-0 slip thread, and the patch was fixed to the diaphragm with an absorbable nail gun (Figure 3). Two drainage tubes were placed in the cavity of the hernia sac and under the abdominal liver margin, respectively. The bleeding was 300 ml without surgical complications. The chest radiograph was re-examined 7 days after operation, and the right lung volume was significantly larger than that before operation. After 1 year follow-up, the pain in the right chest disappeared and there was no special discomfort. The SF-36 quality-of-life scale assessed patients' somatic function at 88 points and social function at 85 points.

A 59-year-old male was admitted to hospital because of "yellow eyes and yellow urine for 3 days". Abdominal CT showed enlarged duodenal papilla, dilated intrahepatic and extrahepatic bile ducts, gallstones and cholecystitis; Endoscopic ultrasound showed hypoechoic occupation of the common bile duct and involvement of the ampulla. Previous history of malignant lymphoma for 22 years, splenectomy for 21 years, and hepatitis B for more than 10 years, untreated. Laparoscopic pancreaticoduodenectomy was performed under general anesthesia. The pancreas was soft and the inner diameter of the main pancreatic duct was 4 mm. Pancreatic duct-to-mucosa anastomosis was performed, and a support tube was placed in the main pancreatic duct (the total length of the support tube was about 12 cm and the diameter was about 5 mm). The support tube is reserved in the intestinal lumen with a length of about 3 cm and is about 10 cm away from the bilioenterostomy, which has a diameter of about 2.5 cm. CT was re-examined one week after surgery, and the support tube was in good position (Figure 1A). The postoperative recovery was smooth without complications. Postoperative pathology: moderately differentiated adenocarcinoma of the lower common bile duct. The patient refused chemotherapy after surgery, and no tumor recurrence and metastasis was found in the follow-up abdominal enhanced CT one year later. The pancreatic duct support tube prolapsed out of the pancreaticojejunostomy and was located in the jejunum, which was considered as the pancreatic duct support tube detached and displaced (Figure 1B). The patient developed melena 2 years after surgery, and no obvious abnormalities were found by gastrointestinal endoscopy. CT showed that the pancreatic duct support tube was located in the right hepatic duct, and the pancreatic duct support tube was considered ectopic (Figure 1C). Endoscopic removal was recommended, and the patient requested follow-up observation. After 5 days, the patient was re-admitted due to hematemesis and melena. CT showed that the support tube was located in the distal small intestine (Figure 1D). No obvious bleeding points were found during DSA in the emergency department. On the same day, fatal hemorrhage and massive jet hematemesis occurred again. Emergency laparotomy was performed: after opening the bilioenterostomy, a large amount of blood gushed out of the right hepatic duct by choledochoscopy during operation. Emergency right hepatic artery ligation + intrahepatic bile duct balloon compression was performed to stop the hemorrhage. Because of rebleeding, vascular embolization was performed twice on the 7th day and the 9th day respectively, and the patient did not rebleed after that. After 8 months, CT reexamination showed changes after right liver embolization, no tumor recurrence was seen (Figure 1E), and there is still tumor-free survival.