2. Hepatectomy
Resection of the diseased liver segment to maximally remove liver lesions containing stones, strictures and dilated bile ducts is the most effective means of treating intrahepatic bile duct stones. This method has been widely adopted and has achieved excellent results.
Intrahepatic bile duct stones are more common in the left lateral lobe and right posterior lobe of the liver. Liver resection is the best way to treat intrahepatic bile duct stones. The postoperative residual stone rate is low and the long-term effect is good.
2.1 Left lateral hepatectomy
Intrahepatic bile duct stones are more common in the left lateral lobe of the liver, and left lateral lobe resection is a relatively simple procedure in liver resection. It can be performed in many primary hospitals and is the most commonly used procedure in liver resection for the treatment of intrahepatic bile duct stones. However, this procedure is mainly used for simple left lateral lobe stones without concomitant stenosis of the left hepatic duct and transverse part and thickening of the bile duct wall. For stones that are not confined to the left lateral lobe of the liver, resection of the left lateral lobe is often not enough. Although stones can be removed from the left inner lobe through the bile duct of the liver section, it is difficult to remove S4a stones, and the stones are often not completely removed, resulting in residual stones after surgery.
2.2 Left hepatectomy
Left hepatectomy is mainly used to treat fibrosis and atrophy of the left liver caused by long-term hepatic duct obstruction such as stenosis of the left hepatic duct or stone incarceration. When the left hepatic duct has stones or stenosis but has not yet caused changes in the liver parenchyma, there are currently two methods: one is to remove the left lateral lobe and explore the bile duct through the liver section to remove stones in the left hepatic duct and the left internal lobe branches; the other advocates left hepatectomy. Dong Jiahong et al. proposed that for regional stones in the left hepatic duct, regular left hepatectomy should be the first choice, rather than only left lateral lobe resection combined with bile duct jejunostomy. Some scholars have also confirmed that for intrahepatic bile duct stones limited to the left internal lobe, left hepatectomy should also be performed if liver function tolerates it, and left lateral lobe resection should be avoided, because the recurrence rate of stones after left hepatectomy is low, and the long-term effect is significantly better than left lateral lobe resection. The author believes that as long as there are clear pathological changes such as stenosis of the left hepatic duct opening and dilatation of the distal bile duct, Regardless of whether the left liver parenchyma is damaged or not, the left hemiliver should be removed actively. If the lesion is indeed limited to the bile duct of the left inner lobe (S4), especially if the left outer lobe is hypertrophic, anatomical left inner lobe resection (S4 segment resection) should be considered. There is no need to sacrifice the normal liver tissue of the left outer lobe unnecessarily.
2.3 Right hepatectomy
The incidence of bile duct stones in the right lobe of the liver is lower than that in the left lobe, so the chances of right hemihepatectomy are also reduced accordingly. When performing right hemihepatectomy for intrahepatic bile duct stones, the selection of surgical indications needs to be strictly controlled, and multiple aspects need to be considered and weighed to ensure safe and smooth surgery and good short- and long-term results. Usually, obstruction of the right hepatic duct or its main branches and recurrent infection lead to extensive damage to the right liver, fibrosis in the portal area, and atrophy of the right liver. At the same time, the left lobe of the liver is compensatory, which makes the proportion of the left and right lobes unbalanced, and gradually rotates clockwise around the inferior vena cava, so that the diseased right lobe of the liver is pushed to the right rear, making surgical exposure and operation more difficult. When removing the right liver lesion of hepatobiliary stones, it is necessary to take a right lateral approach to expose the displaced portal and right hemiliver, fully free the adhesions between the right hemiliver and the posterior abdominal wall and the inferior vena cava, and completely free the entire right hemiliver to facilitate complete resection of the lesion. Intraoperative ultrasound is used to accurately determine the direction of the middle hepatic vein and select the appropriate liver cutting plane for regular resection of the right hemiliver. If the right part of the caudate lobe (caudate process) is involved, it needs to be removed together. However, if the caudate lobe bile duct is not involved and has compensatory hyperplasia, it should be retained in principle.
