Hepatolithiasis has the following characteristics: ① stones are widely distributed, and both left and right hepatic ducts can be involved, but the left hepatic duct is the most common; ② Most stones are silt and fine particles, which are difficult to remove; ③ Often accompanied by chronic cholangitis, annular or segmental bile duct stricture with dilatation above the stricture; ④ Recurrent cholangitis and long-term obstruction can lead to biliary cirrhosis and portal hypertension. In view of this, the treatment of hepatolithiasis with stricture should still follow the surgical principles of "removing stones, relieving stricture, removing diseased liver and unobstructed drainage" proposed by Huang Zhiqiang and others as early as 1970s. However, except for stenosis, 46.7% cases of hepatolithiasis have hepatobiliary duct variation [1 1]. Clinical practice has proved that hepatobiliary duct variation is one of the important reasons for residual stones and reoperation. Therefore, "deformity correction" should be added to the surgical treatment principle of hepatolithiasis and stricture, so as to attract people's attention and attention to the diagnosis and treatment of hepatobiliary malformation. The liver should be examined and explored on a global scale first. 1. Expose the hilar bile duct and take stones directly from the left and right hepatic ducts: after cholecystectomy, cut the common bile duct and the common hepatic duct, take out stones outside the hepatic duct and the hilar bile duct, and explore the lower end of the intrahepatic bile duct and the common bile duct. If stones are found in the openings of the left and right hepatic ducts and the secondary hepatic duct; Because incarceration is difficult to take out, the incision can be extended to the left and right hepatic ducts, and then the stone can be taken out with stone forceps and cholelithiasis spoon. If you have a history of biliary tract surgery, especially multiple operations, the common bile duct and the hepatic portal have severe scar adhesion, and the liver atrophy or compensatory swelling is roughly displaced, it is difficult to expose the hepatic portal and the left hepatic duct trunk upward along the common bile duct. At this time, (dissect the H-shaped model of the liver as much as possible, and pull up the door panel of the liver to fully expose the top of the joint between the left and right hepatic ducts. Editor's note. ) can be used: ① those who have a history of biliary-intestinal anastomosis can cut open the intestinal loop and look for exposure along it; ② Split the liver parenchyma along the sagittal plane at the junction of the left and right hepatic halves, and reach the junction of the left and right hepatic ducts; ③ The position of hilar bile duct is high, the left and right hepatic ducts are narrow, and the hepatic quadrate lobe is large. Wedge resection of the bottom of the hepatic quadrate lobe or resection of the hepatic quadrate lobe can be performed [12]. If the left inner lobe of the liver or the left lobe of the liver is enlarged and the right lobe of the liver is smaller or atrophied, the right costal cartilage arch of Zheng's [13] is removed and the lumbar bridge is raised, so that a good exposure of the hepatic portal can be obtained. The treatment of hepatolithiasis complicated with stricture is mainly to remove stones and stricture rings or segments of hilar bile duct, left and right bile duct trunks and grade II bile duct branches, while stones and strictures of grade III or smaller bile duct branches are mainly treated by hepatectomy and unobstructed biliary drainage. Some authors [14] performed tongue-shaped resection of hepatic hilum tissue for high bile duct stenosis, common hepatic duct, left and right hepatic hilus, hepatic duct above grade II, accompanied by enlargement of hepatic quadrate lobe, so that the hepatic hilum was fully exposed, and the stenosis was formed under direct vision, and the passage was opened, so that the enlarged bile duct was anastomosed with jejunum. It is a new method to expose the third-grade bile duct of the right liver through sulcus incision [15] on the diaphragm or dirty surface of the right liver. Good lithotomy effect can be obtained for the bile duct of the right anterior lobe and the posterior lobe. Fiberoptic choledochoscope, B-ultrasound and cholangiography are used to examine intrahepatic bile duct during operation to confirm or further understand the situation of stones and strictures, and can also be used as a means to judge whether to take stones during operation, which is conducive to the selection of operation methods and the improvement of operation effect. 2. Resection of diseased liver: Lobectomy is the most effective method to treat hepatolithiasis and stricture. Combined with hepatectomy, the therapeutic effect is generally better than that of simple common bile duct jejunostomy. The indications of hepatectomy are: ① left or right hepatic duct stones and strictures with obvious fibrosis of the liver; ② For stones and strictures confined to the primary or secondary branches of a section of hepatobiliary duct, it is difficult to remove stones and correct strictures by other methods, and it is feasible to perform hepatectomy or hemihepatectomy; ③ Patients with hepatobiliary stricture complicated with multiple liver abscesses, extrahepatic biliary fistula, hepatobiliary pleural bronchial fistula and hepatobiliary canceration must undergo hepatectomy; ④ Bilateral intrahepatic bile duct stones with obvious stricture or tension and cast stones in one hepatic duct, unilateral hepatectomy and contralateral hepatic duct anastomosis are feasible; Some people also advocate the resection of one or part of the diseased liver lobe or part of the liver tissue with severe bilateral lesions; ⑤ Cystic dilatation of intrahepatic bile duct with stones, especially those suspected of canceration; ⑥ For stones confined to a certain hepatic segment, the hepatic segment should be removed; ⑦ Partial resection of hepatic quadrate lobe aims to expose highly narrow hilar bile duct. Due to long-term chronic stricture of hepatobiliary duct, fibrosis and atrophy of hepatic lobe, compensatory hypertrophy and hyperplasia of adjacent liver, and extremely irregular liver shape. Therefore, in hepatectomy for hepatolithiasis, regular resection is not emphasized, and the liver tissue with severe lesions, stenosis, dilatation and stones is mainly removed to remove the main lesions in the liver and preserve the functional liver tissue as much as possible. After hepatectomy, the residual stones can be taken out through the hepatic bile duct, and the bile duct can be drained smoothly. Because the diseased hepatobiliary duct is full of stones and purulent bile, it is heavily polluted and has poor blood circulation. If the proximal bile duct is still diseased, it is difficult for the omentum to cover this segment after repeated abdominal surgery. Such patients have more complications after hepatectomy, and are prone to biliary fistula, transection and subphrenic infection. Therefore, it is very important to fully and effectively drain the cross section, subphrenic and biliary tract. 3. Incision and plastic surgery for bile duct stricture and biliary-intestinal drainage: Bile duct stricture of hilum and intrahepatic bile duct is an important reason for bile duct reoperation [16], and it is also the main reason for stone regeneration. The correct treatment of hilar bile duct stenosis directly affects the curative effect of the operation. The basic point of its treatment is to cut the bile duct at the upper and lower ends of the stenosis longitudinally and sew the adjacent bile duct flaps accordingly. Repair the tissue defect with intestinal loop, intestinal slice, gallbladder slice or other tissues, and the cut bile duct wall becomes the back wall of the new anastomosis. In order to take stones under direct vision, it is an inevitable way to cut the second and third grade hepatobiliary ducts. Extensive incision of hilar bile duct can be used to explore grade ⅳ hepatobiliary duct or its opening under direct vision, and large-diameter hilar cholangioenterostomy can undoubtedly remove stones more effectively or reduce residual stones in liver. When the intrahepatic bile duct is widely cut, it must conform to the anatomical principles. (1) In-situ plastic surgery to correct stenosis: For annular stenosis with limited openings of left and right hepatic ducts or common bile ducts, there are few scar tissues around the hepatic ducts, slight liver lesions and few intrahepatic bile duct stones, which can be taken out with instruments or by hepatectomy. Oddi muscle functions normally, and the stenosis ring can be cut, the bile duct walls on both sides of the stenosis ring can be sutured, and the lumen can be enlarged. If the defect is large, pedicled umbilical vein, gallbladder wall and gallbladder wall can be used. Intrahepatic secondary bile duct stenosis, such as diaphragm, can be reconstructed by a method similar to sphincteroplasty. In the treatment of hepatolithiasis and stricture, we should strictly grasp the indications of the surgical method for repairing hilar bile duct stricture. In-situ plastic surgery for bile duct stenosis in general, especially for hilar bile duct, is only suitable for cases of extrahepatic bile duct thickening. (2) Dilation and support of narrow bile duct: After incision and plastic surgery, it can be supported by T-tube short arm. If it is segmental stenosis of left and right hepatic duct or grade II and III bile duct stenosis, and the location is deep, there is no indication of hepatectomy or the patient's condition does not allow hepatectomy, T-tube, U-tube, balloon and water sac catheter can be used for support to consolidate the effect after expansion or incision and plastic surgery. If the stricture is supported by expandable metal support tube (EMS), the effect will be better and safer. During the operation, it is suggested that dilators should be placed in bile duct stenosis. 3 ~ 4 weeks after operation, the inflatable dilatation was successful, and then the silica gel internal and external bile duct support catheter was inserted into the stenosis. (3) Biliary-intestinal drainage: On the basis of the above-mentioned anatomy of bile duct, the bile duct stricture of hilar bile duct and II and III branches which are widely distributed in hilar bile duct are anastomosed with the jejunum stoma. A lot of experience has proved that it is a feasible and commonly used method to relieve stenosis, and it also has a good effect on the second and third branches of the hepatobiliary duct in the liver, such as the left hepatobiliary duct and the third-level bile duct bypass. Because of the complexity and diversity of the scope and degree of lesions in patients with hepatolithiasis and stricture, it is difficult to treat all patients with one biliary drainage method, and corresponding surgical methods must be taken according to the specific situation to achieve the purpose of unobstructed drainage. In order to ensure its curative effect, it should be noted that biliary drainage is one of the comprehensive surgical measures to treat hepatolithiasis and bile duct stenosis. First of all, it is necessary to ensure that the anastomosis is free from stenosis, obstruction and lesions, because biliary drainage can not replace surgery to effectively treat hepatolithiasis and dilatation, otherwise it will aggravate the development of cholangitis and serious complications. Roux-Y anastomosis of bile duct and jejunum inside and outside the liver is the most commonly used way of biliary and intestinal drainage. However, on the one hand, the anastomosis destroys the normal physiological channel, causing changes in the intestinal environment, and the disorder of gastrointestinal hormone secretion increases the secretion of gastric acid, which can induce peptic ulcer; On the other hand, due to the reflux of intestinal contents, cholangitis and stricture of intrahepatic bile duct or anastomosis are easily caused. Therefore, anti-reflux is a difficult problem after hepatolithiasis and biliary reconstruction. Therefore, many anti-reflux anastomosis methods have been put forward one after another, such as early synchronous anastomosis and late rectangular flap anastomosis, artificial intussusception, artificial nipple, inserted jejunum anastomosis and increasing the length of open intestine, which have achieved certain results. Another commonly used operation is interposition of jejunum, bile duct and duodenum anastomosis, which conforms to the physiological state. Because the jejunum interposition is short (about 15cm), it is inevitable to add artificial nipple or valve, and the short-term effect is better. In addition, the modified Roux-en-Y operation [17], subcutaneous blind Roux-en-Y operation [18], Oddi sphincterotomy [19] and choledochoduodenectomy were also reported recently. Choledochoduodenectomy is rarely used for hepatolithiasis, but it is suitable for elderly patients. Intrahepatic bile duct stones and lesions were completely removed without stenosis; Extrahepatic bile duct dilatation (>1.5 cm); People who have undergone subtotal gastrectomy. This operation is contraindicated for patients with intrahepatic bile duct stenosis. Some authors [20] suggested that the jejunum blind loop should be fixed to the abdominal wall at the same time of cholangioenterostomy, which is convenient for choledochoscopy to remove stones after operation, and can also be used to dilate and support the narrow bile duct, and can also be used to drain the bile duct during acute cholangitis. (4) Types and correction of hepatobiliary malformations: There are many types of hepatobiliary malformations, but the main malformations caused by lithotripsy and reoperation are: the caudate lobe bile duct opens in the right anterior lobe or the right posterior lobe bile duct, the left or right hepatic duct is absent, the right anterior lobe bile duct opens in the left hepatic duct, and the right posterior lobe bile duct tree is separated. The correction methods of hepatobiliary malformation mainly include angle correction and shortcut surgery [1 1]. The above operations are effective in treating hepatolithiasis complicated with stricture, and it is unwise to try to replace other operations with one operation. The long-term curative effect of hepatolithiasis with stricture can be improved by the combined application of various surgical methods, including portal hypertension. 4. Treatment of residual stones: In addition to reoperation, various non-surgical treatments are also widely used for residual stones. (1) Lithotripsy and choledochoscopy: This method is an important method to treat hepatolithiasis. The main ways to enter the intrahepatic bile duct are the sinus formed by indwelling T tube after operation, the subcutaneous jejunal loop and the expanded PTCD sinus after cholangioenterostomy. T-tube sinus choledochoscopy can usually be performed 4 ~ 6 weeks after operation. However, this method is often not easy to succeed when the stone is embedded and located too deep. Electro-hydraulic vibration wave lithotripsy is one of the most respected lithotripsy technologies. In addition, high-frequency current lithotripsy and laser lithotripsy are also commonly used lithotripsy methods. (2) Lithotripsy: There are two clinical methods to dissolve stones: oral and direct. There is no obvious progress in the former solvent, and there is no effective litholytic agent. In recent years, the research on direct solvents has developed rapidly, and a number of effective solvents such as EDTA-2Na-UDCA- heparin solution and GMDC have appeared, and there are many reports on dissolving and softening pigment stones. However, there are still some problems such as uncertain curative effect and serious digestive tract reaction after use, which need to be further improved. The main way to inject solvent is through postoperative T tube, PTCD tube and nasobiliary duct.