腹腔镜胆囊切除术中胆管损伤的原因及处理

目的:分析腹腔镜胆囊切除术胆管损伤的原因并探讨防治措施.方法:回顾分析2012例腹腔镜胆囊切除术中8例胆管损伤的临床资料. 结果5例行胆肠Roux-Y吻合术,1例行胆管端端吻合、T管支撑引流术,1例行总胆管修补T管引流术,1例行钛夹取出T管引流术. 结论胆管横断伤是腹腔镜胆囊切除术中的最严重并发症,将总胆管误认为胆囊管予以切断是本型损伤的根本原因,切断胆囊管前辨明"三管"关系是预防本型损伤的关键.     

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由于腹腔镜胆囊切除术的应用和普及,越来越多的医生能够掌握和应用腹腔镜进行胆囊切除术,但随之而来的胆管损伤的发生率也在随之增高(0.3%～1.4%)。胆道手术是引起胆管损伤的主要原因[1],在医源性胆管损伤中,90%发生于胆囊切除术,故胆管损伤是外科常见的手术并发症。如果处理不     

腹腔镜胆囊切除术并发症的防治

目的探讨腹腔镜胆囊切除术(LC)的并发症及预防、处理措施。方法回顾分析794例腹腔镜胆囊切除术并发症的临床资料。结果发生各类并发症11例(1.38%),其中腹腔内出血2例,胆管损伤1例,胆漏2例,胆总管残余结石2例,切口感染1例,皮下气肿1例,胃肠道损伤2例。死亡1例,病死率0.13%。结论胆管损伤、腹腔出血、胆漏是腹腔镜胆囊切除术的主要并发症,遵守操作规范,及时中转剖腹可预防并减少并发症的发生。     

腹腔镜胆囊切除术胆漏的防治

目的:探讨腹腔镜胆囊切除术后胆漏的原因、预防方法及处理措施.方法:对280例腹腔镜胆囊切除术后5例胆漏患者的临床费料进行回顾性分析.结果:本组患者胆总管损伤1例,经修补并置管引流治愈;4例术后胶管引流出胆汁,未经特殊处理而治愈.结论:肝外胆管、速走胆管损伤及胆囊管残端漏是腹腔镜胆囊切除术后胆漏的主要原因,建立通畅的腹腔引流,行胆总管修补、T管支持引流或胆肠吻合是治疗腹腔镜胆囊切除术后胆漏、预防并发症出现的主要方法.     

腹腔镜胆囊切除术并发症的防治

目的避免经腹腔镜行胆囊切除术(LC)并发症的发生。方法回顾性总结分析本院行经腹腔镜胆囊切除术368例。结果胆管损伤1例,胆囊管残端瘘1例,胆囊动脉后支撕脱出血1例。结论严格的术前检查和规范的手术程序可大大减少腹腔镜胆囊切除术的并发症。并发症是导致腹腔镜胆囊切除术中转开腹及术后再手术的主要原因,做好LC的关键是预防其并发症,特别是严重并发症的发生,根据其发生原因加以预防就显得十分重要。     

腹腔镜胆囊切除术胆管损伤问题探讨（附15例报告）

目的　探讨与分析腹腔镜胆囊切除术胆管损伤原因、类型及预防措施。方法　对近 6年来 11796例腹腔镜胆囊切除术及 15例 ( 0 .13 % )胆管损伤进行综合分析。结果　 15例胆管损伤中 ,横断伤 6例 ( 0 .0 5 % ) ,电灼性胆管伤 6例 ( 0 .0 5 % ) ;分离性损伤 3例 ( 0 .0 2 5 % )。横断伤处理以胆肠Roux Y吻合为主 ,电灼伤及分离伤以引流为主 ,个别放置T型管引流。15例均获治愈。结论　胆管损伤常见 4种类型。重视预防及手术技巧的改进 ,器械的更新 ,能降低腹腔镜胆囊切除术中胆管损伤的发生率。恰当的处理方法可以使患者获愈     

腹腔镜胆囊切除术并发症的预防和处理

目的探讨腹腔镜胆囊切除术并发症发生的原因、预防及处理。方法回顾分析及总结我院施行830例腹腔镜胆囊切除术患者的临床资料。结果术后胆囊床迷走胆管漏1例,术中发现胆管损伤1例,中转开腹15例,成功813例。结论腹腔镜胆囊切除术时预防手术并发症需要细心操作和正确的技术,认真选好手术适应证,把握中转手术的时机,是降低手术并发症发生的重要措施。     

腹腔镜顺逆结合胆囊切除术预防胆管损伤的临床分析

目的 探讨腹腔镜顺逆结合胆囊切除术预防胆管损伤并发症的临床价值.方法 回顾性分析1991年3月-2006年6月间腹腔镜顺逆结合胆囊切除术613例的临床资料.结果 613例中胆囊结石伴胆囊萎缩121例,急性、亚急性胆囊炎432例,胆囊结石伴慢性胆囊炎42例,胆囊息肉18例.中转开腹9例,（5例为胆囊结石伴胆囊萎缩,4例亚急性胆囊炎）.平均手术时间43.5 min,术后仅1例发生毛细胆管漏,经引流3d痊愈,其余患者均顺利恢复,无胆管损伤病例,无出血、感染及死亡等严重并发症发生.平均术后住院日5.5 d.结论 腹腔镜顺逆结合胆囊切除术能提高腹腔镜胆囊切除术的成功率,减少了腹腔镜胆囊切除术胆管损伤并发症的发生,特别是Calot三角解剖不清或变异时,此手术方法更有效.     

腹腔镜胆囊切除术肝外胆管损伤的预防

目的探讨腹腔镜胆囊切除术肝外胆管损伤的预防。方法收集我院650例腹腔镜胆囊切除术的临床资料,总结预防手术肝外胆管损伤的方法。结果650例腹腔镜胆囊切除术有1例肝外胆管损伤,发生率0.17%。结论腹腔镜胆囊切除术通过严格选择手术适应证,注意胆道系统的解剖学变异,正确处理复杂病理改变,在困难的腹腔镜胆囊切除术中适时中转开腹,可以减少腹腔镜胆囊切除术的肝外胆管损伤。     

腹腔镜胆囊切除术后胆漏的原因分析

目的探讨腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)后胆漏的原因及防治方法。方法总结LC后并发8例胆漏的诊治经验。结果 LC后8例胆漏病例中肝外胆道损伤2例,肝总管壁电凝烧灼伤1例,胆囊床毛细胆管渗漏3例,迷走胆管漏1例,胆囊管钛夹脱落1例。均经相应治疗痊愈出院。结论肝外胆管、迷走胆管损伤及胆囊管残端钛夹脱落是腹腔镜胆囊切除术后胆漏的主要原因,建立通畅的腹腔引流,行胆总管修补、T管支持引流或胆肠吻合是治疗腹腔镜胆囊切除术后胆漏、预防并发症出现的主要方法。     

腹腔镜胆囊切除术致胆管损伤17例分析

目的:探讨腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)致胆管损伤的原因及处理方法。方法:回顾分析LC致胆管损伤17例患者的临床资料(11例胆总管损伤,4例肝总管损伤,2例右肝管损伤),并分析其原因及处理方法。结果:20000例LC中发生胆管损伤17例,占0.085%(17/20000),胆管损伤的主要原因是解剖变异,周围组织粘连,局部充血水肿。主要行胆肠Roux-en-Y吻合,T管支撑引流,尿管支撑引流并直接吻合瘘口等。17例胆管损伤患者经过上述处理后均痊愈出院,随访半年以上,恢复良好。结论:胆管损伤是LC术中严重且常见的并发症,掌握胆囊三角的解剖技巧,处理好胆囊管、胆囊动脉是减少胆管损伤的关键。对解剖异常,粘连严重,局部充血水肿的患者应给予高度重视,一旦发现胆管损伤及时中转开腹,经过及时有效的处理,可避免严重后果。     

选择性胆道造影在腹腔镜胆囊切除术中的应用

目的探讨腹腔镜胆囊切除术（laparoscopy cholecystectomy,LC）中开展选择性的胆道造影技术及其临床应用价值。方法对98例术中胆道造影患者的临床资料进行回顾性分析。结果同期LC 862例,术中胆道造影98例,造影成功90例,成功率为91.8%。术中发现胆管结石7例,胆管损伤1例,胆道解剖异常2例。结论选择性术中胆道造影操作简便安全,成功率高,显影清晰,可有效降低胆管结石的残余率和胆管损伤的发生率,避免不必要的胆道探查,提高LC手术的安全性。     

腹腔镜胆囊切除术后胆漏原因及处理

目的探讨腹腔镜胆囊切除术(LC)术后胆漏的原因及诊治对策。方法回顾分析我院1992年5月至2005年7月收治的LC术后胆漏12例的临床资料。结果本组胆道损伤率为0.73%(25/3408),表现为术后胆漏的占36%(9/25)。其中主胆管损伤5例,副肝管损伤7例,除1例迷走胆管损伤未行再手术外,其余11例均再手术,均治愈。结论术后胆漏是LC胆道损伤的特点之一,LC术后不明原因的突发性上腹部剧痛是胆漏的信号。胆漏量<100ml/d,可行B超引导下穿刺置管引流;胆漏量>100ml/d,应及时开腹再手术,根据情况行胆道的修复或重建,若不能行一期修复或重建的可先行经近端胆管插管外引流。     

Value and consequences of routine intraoperative cholangiography during cholecystectomy

Since the introduction of laparoscopic cholecystectomy (LC), an increase in accidental common bile duct (CBD) injuries of up to 1.2-1.6% has been reported. In the present prospective study of 1,710 patients undergoing cholecystectomy (1,241 LC procedures and 469 open cholecystectomies [OC]), we tested the predicative value of routine intraoperative cholangiography (IOC). The IOC was feasible in 92.4% of the cases in the LC group and in 83% of cases in the OC group and presented a complete depiction of the extrahepatic bile system in 98.3%. Anatomic variations of the bile duct system, which influenced the operative management, were found in 13.2% of cases (13.4% LC versus 12.8% OC). In 2.5% of the patients, preoperatively undetected CBD stones were also found. Method-specific complications did not occur in any of the patients. Additionally, in a controlled subgroup analysis of 163 patients, we evaluated preoperative intravenous cholangiography (IVC) and IOC. Intravenous cholangiography showed only 72.4% of the operation-relevant anatomic variations (vs. 100% by IOC); in 6.1% of the cases, there were reactions to the dye (vs. none in IOC), and in only 28.6% of the patients, CBD stones were detected (vs. 71.4% IOC). There were four bile duct injuries (0.29%) during LC and two (0.4%) during OC. All injuries were detected intraoperatively and fixed in the same setting without postoperative complications. In conclusion, we recommend the use of routine IOC during cholecystectomy. By this technique, anatomic variations of the bile duct system will be visualized and therefore accidental injuries will be avoided.     

Iatrogenic bile duct injury: the scourge of laparoscopic cholecystectomy

Background : Laparoscopic cholecystectomy (LC) has become the first‐line surgical treatment of calculous gall‐bladder disease and the benefits over open cholecystectomy are well known. In the early years of LC, the higher rate of bile duct injuries compared with open cholecystectomy was believed to be due to the ‘learning curve’ and would dissipate with increased experience. The purpose of the present paper was to review a tertiary referral unit’s experience of bile duct injuries induced by LC. Methods : A retrospective analysis was performed on all patients referred for management of an iatrogenic bile duct injury from 1981 to 2000. For injuries sustained at LC, details of time between LC and recognition of the injury, time from injury to definitive repair, type of injury, use of intraoperative cholangiography (IOC), definitive repair and postoperative outcome were recorded. The type of injury sustained at open cholecystectomy was similarly classified to allow the severity of injury to be compared. Results : There were 131 patients referred for management of an iatrogenic bile duct injury that occurred at open cholecystectomy (n = 62), liver resection (n = 5) and at LC (n = 64). Only 39% of bile duct injuries were recognized at the time of LC. Following conversion to open operation, half the subsequent procedures were considered inappropriate. When the injury was not recognized during LC, 70% of patients developed bile leak/peritonitis, almost half of whom were referred, whereas the rest underwent a variety of operative procedures by the referring surgeon. The remainder developed jaundice or abnormal liver function tests and cholangitis. An IOC was performed in 43% of cases, but failed to identify an injury in two‐thirds of patients. The bile duct injuries that occurred at LC were of greater severity than with open cholecystectomy. Following definitive repair, there was one death (1.6%). Ninety‐two per cent of patients had an uncomplicated recovery and there was one late stricture requiring surgical revision. Conclusions : The early prediction that the rate of injury during LC would decline substantially with increased experience has not been fulfilled. Bile duct injury that occurs at LC is of greater severity than with open cholecystectomy. Bile duct injury is recognized during LC in less than half the cases. Evidence is accruing that the use of cholangiography reduces the risk and severity of injury and, when correctly interpreted, increases the chance of recognition of bile duct injury during the procedure. Prevention is the key but, should an injury occur, referral to a specialist in biliary reconstructive surgery is indicated.     

胆囊管异常汇合的诊断及其在腹腔镜胆囊切除术中的意义

目的 分析逆行胰胆管造影术（ERCP）在诊断胆囊管异常汇合的价值及其在预防腹腔镜胆囊切除术（LC）胆管损伤等并发症中的作用。方法 我院从1992年7月至1999年6月共行LC4 500余例,其中对780例LC患者术前行ERCP检查。选择胆囊管、肝总管和胆总管三者解剖关系均清楚的772例ERCP片,观测其胆囊管异常汇合情况,测量其长度和直径,并与100例胰胆管无异常的ERCP片对比。结果 在780例ERCP检查者中,发现胆囊管异常汇合者125例（16.03%）。该780例行LC中,中转开腹胆囊切除术35例（4.49%）,发生各种并发症6例（0.77%）。但无胆管损伤等严重并发症发生。结论 ERCP能准确诊断胆囊管的各种异常汇合,在预防LC胆管损伤等胆道并发症的发生中起重要作用。     

内镜联合腹腔镜治疗胆囊结石合并肝外胆管结石

目的 :探讨运用内镜联合腹腔镜治疗肝外胆管结石的方法。方法 :对胆囊结石合并胆总管结石患者 ,5 1例行开腹胆囊切除 +胆总管探查术 ,4 0例行内镜下十二指肠乳头切开取石术 (EST) +腹腔镜胆囊切除术 (LC) ,比较两者临床疗效、住院时间、并发症等。结果 :开腹组术中结石取净率为 88 2 % ,住院时间为2 1.9± 7.2d ,术后并发切口感染 1例。内镜组中有 2例取石失败 ,改行开腹 ,余均取石成功 ,取石成功率为95 % ,住院时间为 10 3± 4 5d ,无严重并发症。结论 :与传统的开腹胆囊切除加胆总管探查术相比 ,EST +LC治疗胆囊结石合并肝外胆管结石具有创伤小、住院时间短、患者康复快、并发症少等优点 ,此种方法可代替大部分开腹胆囊切除术加胆总管探查术     

腹腔镜胆囊切除术中胆管损伤的预防及处理

目的探讨腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)中胆管损伤的原因、预防措施及处理方法。方法1999年10月至2009年10月行LC7431例,术中发生胆管损伤16例,对其临床资料进行回顾性分析。结果16例胆管损伤病人,术中发现12例(75.00%)。损伤类型为:高位胆管损伤2例,胆总管横断4例,右肝管横断2例,迷走肝管及副肝管损伤4例,右肝管电灼伤1例,肝总管电灼伤1例,胆囊管拔断1例,胆囊管与胆总管交汇处撕裂1例。结论腹腔镜下胆管损伤的原因是多方面的,注重胆囊Calot三角区的操作技巧及复杂胆囊的对策,可显著减少胆管损伤的发生;对于胆管损伤应争取术中尽早发现,适时恰当处理。     

腹腔镜胆囊切除术中转开腹原因分析

目的 探讨腹腔镜胆囊切除术(LC)中转开腹的原因。方法 回顾性分析1998年4月～2002年3月本院LC术中转开腹病例的临床资料。结果 1368例LC中，中转开腹60例，中转率4．39％。中转开腹的原因：腹腔内及Calot三角粘连17例，急性胆囊炎或急性胆囊炎恢复期14例，胆囊癌2例，胆肠内瘘5例，胆总管结石2例，萎缩性胆囊炎6例，出血2例，胆道损伤2例，Minizi综合征2例，胆漏1例，黄色肉芽肿性胆囊炎1例，其它原因6例。结论 Colat三角解剖不清是LC中转开腹的主要原因，也与手术的技术水平和经验有关。     

腹腔镜胆囊切除术前行MRCP对肝外胆道变异诊断的临床意义

目的:探讨腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)术前行MRCP检查对肝外胆道变异诊断的临床意义。方法:回顾分析为1 200例LC患者术前行MRCP检查的临床资料。结果:LC术前通过MRCP检查发现肝外胆道变异96例,其中胆囊管冗长且扭曲51例、胆囊管低位汇合23例、胆囊管汇合于右肝管8例、迷走胆管5例、副胆管4例、胆总管囊肿2例、双胆囊2例、肝内胆囊1例。手术证实89例与术前MRCP检查结果一致,存在胆道变异。结论:通过MRCP检查可全面了解胆树图像,LC术前便可发现各种胆道变异及胆道的复杂性,具有一定的导航作用,克服了以往术中经验性、探索性解剖Calot三角的缺点,明显减少了医源性胆道损伤的发生。