Objective To summarize the anatomical variations of the Calot's triangle and explore the best method to manage the variations during laparoscopic cholecystectomy(LC).Methods From December 2006 to December 2008,158 patients with anatomical variation of the Calot's triangle received LC,the clinical data of the cases were reviewed retrospectively.Results Among the cases,15 patients were converted to open surgery because of Ⅰ type Mirizzi syndrome(3 cases),Ⅱ type Mirizzi syndrome(4 cases),low location of the convergence of the cystic duct and the common bile duct(2 cases),cystic duct opening into the posterior wall of the common bile duct(2 cases),the cystic duct and common bile duct sharing 2-cm lateral wall(1 case),severe adhesion of the Calot's triangle(2 cases),and hemorrhage of the posterior cystic artery(1 case).The LC were completed in 143 patients,among which 5 cases had postoperative complications,including biliary leakage in 1 case(cured by a second operation),bleeding at the puncture sites in 2 patients,infection of the puncture site in 1 case,and residual cystic stones in 1 case(cured by ERCP in 2 weeks).Conclusions Knowledge of the anatomical variations of the Calot's triangle is the key to LC.Different surgical strategies should be carried out according to the dissection of the Calot's Triangle area,and the location of the common hepatic duct and common bile duct.

Objection To study the p21 WAF1 and p53 protein expression in patients with cholangiocarcinoma and its relation to the pathologic grading and metastasis of the tumor.[WT5”HZ] Methods Using immunohistochemical method, we examined p21 WAF1 and p53 protein expression in 48 cases of cholangiocarcinoma and 8 cases of biliary duct tissue with chronic inflammation.[WT5”HZ] Results The expression of p21 WAF1 and p53 was positive in 25% and 54% respectively of the cases with cholangiocarcinoma, and 88% and 0% respectively of the cases in normal bile duct tissue with chronic inflammation (all P

Objective To summarize clinical experience of emergent surgery for severe liver trauma with rupture of major blood vessels. Methods The clinical data of 12 cases suffering from severe liver trauma with rupture of perihepatic and intrahepatic large blood vessels were retrospectively analyzed. These cases were from Dec 2000 to May 2008. All the cases underwent emergency operation, 6 cases were treated with liver lobectomy: among those 1 case with right posterior lobe liver resection, 1 case with irregular right lobe liver resection, 3 cases with left hemihepatectomy, and 1 case with left lateral lobectomy. Seven cases with rupture of major blood vessels were treated by repair or ligature and/or packing including repair of posthepatic inferior vena though the middle fissure in 2 cases, and through retrahepatic space in one case, interrupted suture of the portal vein in 2 cases, interrupted suture of the right hepatic veins in 2 cases. Mattress suture was applied to the ruptured hepatic veins in 7 cases including mattress suture of the branch of right hepatic vein and middle hepatic vein in 1 case, mattress suture of right hepatic vein in 1 case, suture of middle hepatic vein in 2 cases, and suture of left hepatic vein in 3 cases. One case was treated with ligation of hepatic artery and 3 cases with gauzes packing. Results Among all the 12 cases, 9 cases were cured, 3 cases died: two were caused by severe trauma together with hemorrhagic shock, one by sever brain injury together with hemorrhagic shock. Conclusions Prompt operation, precise stop bleeding and correct operation style are the key for successful rescue of patients suffering from severe liver trauma and massive bleeding.

Objective To evaluate the efficacy of surgical repair for non-circumferential defect of bile duct in Mirizzi syndrome.Method The clinical data of 32 patients with Mirizzi syndrome with non-circumferential defect of bile duct were repaired using the patient's own tissues such as gallbladder pedicle flap,umbilical venous flap and omental flap.Results All the patients were operated success fully.There was no operative mortality.The defects in the bile duct were repaired using gallbladder pedicle flap in 25 patients,umbilical venous flap in 5 patients and omental flap in 2 patients.There were 2 patients who developed postoperative complications.There was one postoperative bile leakage in a patient who was repaired using an umbilical venous flap.The other complication was residual bile duct stones.The patient with postoperative bile leakage was drained through a drainage tube which was removed after 7 days.The residual bile duct stones were removed by endoscopy through a T-tube sinus after 9 months.All patients were confirmed by T-tube cholangiography after 9 to 12 months to have no stones,bile duct stenosis or any other abnormalities.The T-tube was then removed.All patients were followed -up for 1 to 5 years.All patients had no cholangitis,abdominal pain,jaundice or fever.Conclusions Using the patients' own tissues such as gallbladder pedicle flap,umbilical venous flap and omental flap to surgical repair the defect in the bile duct of patients with Mirizzi syndrome was effective.This surgical treatment is a good choice.

Objective To analyze characteristics of severe liver trauma and efficacy of different surgical procedures. Methods Clinical data of 109 patients with severe liver trauma treated in the recent 10 years were retrospectively analyzed. Debriding suture was performed in 32 patients, gauze tamponade in 5, debridement hepatectomy in 59 and anatomical hepatectomy in 13 patients. Results In all the 109 patients, 92 were cured and 17 died. The dead patients included 3 with grade Ⅲ trauma,9 with grade Ⅳ trauma, and 5 with grade V trauma. Among the dead patients, there were 3 patients with simple liver injury (17.6%) and 14 with associated injury (82.4%). Conclusion Right hepatic serious damage is the main type of severe liver trauma and is always complicated with associated injury and needs emergency treatment. Application of the most appropriate surgical approach according to the traumatic condition is important to promote the successful rate of treatment.

Objective To study the results of laparoscopic approach in the treatment ot gallbladder and common bile duct stones.Method The authors reviewed data of 60 patients with gallbladder and bile duct stones treated laparoscopically.Results All the 60 patients treated with laparoscopic cholecystectomy and laparoscopic transcystic common bile duct exploration (LcTDE) were successful.There were 1 bile duct stone in 32 patients,and 2 to 6 bile duct stones in 28 patients.The operation time was (38.7±15.1) min and the hospitalization time was (5.5±2.1) days.One patient developed biliary fistula postoperatively which healed after 7 days of conservative treatment.One patient had bile duct residual stone which was treated by ERCP.The remaining patients were well.Conclusion Laparoscopic transcystic common bile duct exploration using a mini incision and primary suturing of the bile duct was simple,safe and efficacious.

Objective To evaluate the effect of debridement hepatectomy with selective hepatopetal blood occlusion in the treatment of severe hepatic trauma.Methods The clinical data of 55 patients with severe hepatic trauma treated by debridement hepatectomy with selective hepatopetal blood occlusion were retrospectively analyzed.20,20 and 15 patients were with grade Ⅲ,Ⅳ and Ⅴ hepatic trauma respectively,combined with major peripheral hepatic vascular injury in 14 cases and with other trauma in 35 cases.Additional procedures including liver suture repair in 7 cases,perihepatic gauze packing in 3 cases,inferior vena cava repair in 5 cases,hepatic vein repair in 4 cases,hepatic vein ligation in 3 cases and hepatic artery ligation in 2 cases were performed.Other operations such as craniotomy debridement in 3 cases,cholecystectomy in 6 cases,T tube drainage of common bile duct in 4 cases,splenectomy in 5 cases,pancreatic tail resection in 2 cases,left kidney resection in 1 case,thoracic cavity closed drainage in 9 cases,partial small bowel resection or repair in 4 cases and stomach repair in 1 case were performed as needed.Results The operations were successful in 47 patients.Postoperative complications were observed in 19 cases (34.5％) including coagulation disorders in 1 case,postoperative abdominal bleeding in 2 cases,intestinal obstruction in 1 case,liver and renal dysfunction in 4 cases,abdominal infection in 3 cases,incision infection in 2 cases,pulmonary infection in 4 cases,pleural effuion in 10 cases.Death occurred in 8 patients (14.5％),the cause of death were hemorrhagic shock in 3 cases,combined with severe craniocerebral injury in 2 cases,septic shock in one case,and multiple organ failure in 2 cases.Conclusions Debridement hepatectomy with slective hepatopetal blood occlusion is an effective treatment for severe hepatic trauma.

Objective To study the pathological changes of acute hemorrhagic necrotizing pancreatitis(AHNP) complicated with acute lung injury(ALI). Method The model of AHNP with ALI was established in rats. The changes of function and structure of pancreas and lung were observed. Results One hour after induction of the model , pancreas showed mild edema and congestion . 12 hours after introduction of the model , the typical pathological changs of AHNP were found . The lung extravascular water volume and levels of PaCO 2 increased significantly, and the PaCO 2 decreased obviously. Morphological examination demonstrated that inflammatory cell , insterstitial edema , intra-alveolar hemorrhage ,desquamate and disintegration occurred in the lungs. Conclusions The pancreatic and pulmonary morphologic changes in this model is similar to the changes in clinical AHNP with ALI , which suggests that the model can be used to study the mechanism of AHNP with ALI and evaluate the effect of drugs for AHNP with ALI.

Objective To evaluate the anatomical basis of retrohepatic tunnel used for liver hanging maneuver.Methods The anatomy of inferior vena cava ( IVC ) was studied in 20 healthy adult cadavers and 15 patients with advanced cirrhosis who underwent piggyback liver transplantation to confirm the existence of the path of retrohepatic tunnel and count the number of short hepatic veins draining into retrohepatic IVC.Results Short hepatic veins mainly drain into the IVC on its left and right sides.The number of short hepatic veins that drain into the upper or middle portion of the IVC was significantly more than that into the lower portion ( x2 =48.524,P ＜ 0.01 ).On the path of retrohepatic tunnel,most short hepatic veins that drain into the IVC are located on the front side ( F =9.188,P ＜ 0.01 ).There was no significant difference in the number of short hepatic vein between the groups of liver cirrhosis and that of healthy adults ( t =0.405,P ＞ 0.05 ),but anatomic variation of post-hepatic tunnel is common in liver cirrhotics.Conclusions Retrohepatic tunnel was a potential space and had a unique anatomical feature.The establishment of retrohepatic tunnel by liver hanging maneuver is safe in noncirrhotics.However,in advanced posthepatitic cirrhosis,retrohepatic tunnel should be used with caution.

Objective To explore the surgical modality and safety of hepatectomy for hepatic hemangiomas close adjoining the hepatic portal and vital blood vessels. Methods From June 2005 to June 2010 17patients of hepatic hemangiomas underwent hepatectomy. Data were retrospectively analyzed.Results All the 17 cases were operated on successfully. Six cases were treated with anatomic liver lobectomy including right hemibepatectomy through liver hanging maneuver by anterior approach in 2 cases,under right liver blood vessel blochade and anatomic right posterior hepatectomy in 2 cases, left hemihepatectomy in 2 cases. Eight cases were treated by hemangiomas enucleation, in 3 cases hemangioma was enuleated through liver parenchyma splitting under intermittent hepatic blood inflow exclusion. There was no postoperative mortality, postoperatively pleural effussion occured in 5 cases,wound infection occured in 1 case, and pulmonary infection occured in 1 case, all the cases were cured. Conclusions Different operation styles should be applied according to the position, size of hepatic hemangiomas close adjoining the hepatic portal and the important blood vessels.