腹腔镜胆囊大部切除术不闭锁缝合胆囊残端的可行性研究

目的:探讨残留部分胆囊壶腹或困难胆囊行腹腔镜胆囊大部切除术不闭锁缝合胆囊残端的可行性。方法:总结2006年1月至2008年3月16例Calot三角解剖困难患者行腹腔镜胆囊大部切除术中残留部分胆囊壶腹或胆囊管的临床资料,术中胆囊残端不闭锁缝合,分析术后胆漏发生率、持续时间、量及住院时间、胆囊管残留综合征(cholecystic duct remain syn-drome,CDRS)发生率、胆道损伤等。结果:术后发生胆漏5例(31.25%);胆漏持续时间2~5d,平均(3.4±1.1)d;24h最大胆漏量10~150ml,平均(58±57.6)ml;住院时间7~12d,平均(8.7±1.4)d,未发生CDRS及胆道损伤。16例患者均治愈出院。随访1~18个月未发现与手术有关的近远期并发症。结论:Calot三角解剖困难时残留部分胆囊壶腹或胆囊管的腹腔镜胆囊大部切除术,术中不闭锁缝合胆囊残端可以避免发生CDRS及误伤肝外胆管等,出现胆漏经过短期持续腹腔引流后可自愈。腹腔镜胆囊大部切除术不闭锁缝合胆囊残端是安全、可行、有效的手术方法。     

腹腔镜胆囊管结石及胆囊管残株结石的处理体会

目的:总结胆囊管结石的术前诊断及腹腔镜胆囊切除(laparoscopic cholecystectomy,LC)、胆总管探查术的处理措施与技巧,并探讨LC术后早期胆囊管残留结石行腹腔镜胆囊管残株切除术的手术方式、技巧与注意事项。方法:回顾分析27例LC、2例腹腔镜胆总管探查术、2例LC术后早期腹腔镜胆囊管残株切除术的临床资料。结果:31例均顺利完成手术,无中转开腹。LC术中1例肝总管针孔样损伤,用4-0可吸收线缝合修补一针,术后无胆漏发生。结论:胆囊管结石较常见,术前、术中容易漏诊,对于术后早期发生的胆囊管残留结石可行腹腔镜胆囊管残株切除。     

腹腔镜手术中胆囊管结石处理方式的选择

目的 探讨胆囊管结石行腹腔镜胆囊切除术(LC)手术处理方式选择.方法 回顾性分析2007年7月～2011年7月我院肝胆胰脾外科行腹腔镜胆囊切除术成功治愈的48例胆囊管结石病人的临床资料和手术过程.结果 48例均行腹腔镜胆囊切除术,根据胆囊管结石大小与位置采用不同方式将胆囊管远端部分敞开,用弯分离钳自胆总管向胆囊管方向交...     

腹腔镜胆囊大部切除术中胆囊管残端的处理

目的:对比分析腹腔镜胆囊大部切除术(laparoscopic subtotal cholecystectomy,LSC)中胆囊管残端关闭处理和开放处理的效果。方法:回顾分析2001年4月至2009年12月为87例患者施行LSC的临床资料,其中胆囊管残端关闭处理(A组)36例,残端开放处理(B组)51例。结果:所有病例均在腹腔镜下完成手术,无胆管损伤等严重并发症发生。A组术后4例发生胆囊管残留综合征(cholecystic duct remnant syndrome,CDRS),均接受再次开腹手术治愈;B组术后8例轻微胆漏,均自行愈合,无CDRS发生。结论:LSC适于困难条件下的胆囊切除;关闭胆囊管残端有可能导致CDRS,适时选择开放残端安全可行,可减少CDRS的发生。     

Ligating the cystic duct in laparoscopic cholecystectomy

BACKGROUND: In laparoscopic cholecystectomy, bile leak from the cystic duct stump is a recognised postoperative complication. This could be due to dislodgement of the metal clips. Migration of the clip is an added problem. METHODS: Since 1995, 70 patients were included in the study of intracorporeal cystic duct ligation in laparoscopic cholecystectomy. Construction of a ligature is a single handed procedure using a free end of the thread. It is quite different from the other two methods described in the literature. RESULTS: There was not a single case of postoperative morbidity in these patients, but in a retrospective study, postoperative biliary dyspepsia with fatty food was evident in a few patients among those cases in which the liga-clips were applied to the cystic duct. CONCLUSION: The cystic duct ligation with absorbable thread should be a gold standard in laparoscopic cholecystectomy. It reduces the risk of postoperative morbidity.     

The role of ERCP in laparoscopic cholecystectomy-related cystic duct stump leaks

Background: Laparoscopic cholecystectomy has resulted in an increase in the incidence of cystic duct stump leaks. To assess the role of endoscopic retrograde cholangiopancreatography (ERCP) a review of 14 cystic duct stump leaks following laparoscopic cholecystectomy was carried out. Methods: A retrospective chart review of fourteen patients was carried out. There were 11 females and 3 males. Laparoscopic cholecystectomy was carried out without any difficulty. Three patients became very ill soon after surgery while 11 patients were minimally ill. All were still hospitalized after the cholecystectomy. Results: Urgent ERCP on the 3 very ill patients demonstrated a cystic duct bile leak. In the 11 minimally ill patients, ultrasonography demonstrated intraabdominal fluid collections and initial treatment was percutaneous drainage. Only 2 of the 11 patients improved. The remaining nine patients developed a septic course. ERCP was carried out and demonstrated cystic duct bile leak in all 9 patients. Endoscopic papillotomy alone or endoscopic papillotomy plus stenting resolved the clinical picture. Conclusions: Patients who are ill post laparoscopic cholecystectomy should have urgent ERCP. Cystic duct bile leaks should be managed by endoscopic papillotomy and in select cases, stenting.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Orlando, Florida, USA, 11–14 March 1995     

Migration of endoclip into duodenum

The long-term effect of spilled clips within the abdominal cavity after laparoscopic cholecystectomy is unknown. However, most surgeons agree that the migration of clips has limited clinical consequences. A few cases have been reported of clips that have migrated into the common bile duct, causing stone formation and/or obstructions. We present a case of gallstone pancreatitis treated with laparoscopic cholecystectomy that was complicated by bile leakage from the cystic duct stump 1 day after the procedure. Although the leaking stump sealed itself spontaneously after the placement of a biliary stent, a clip had migrated directly to the superior wall of the first portion of the duodenum. Herein the details of the patient's history are presented. We also discuss the possible mechanisms of clip migration and describe some preventive measures.     

Migration of endoclip into duodenum. A rare complication after laparoscopic cholecystectomy

The long-term effect of spilled clips within the abdominal cavity after laparoscopic cholecystectomy is unknown. However, most surgeons agree that the migration of clips has limited clinical consequences. A few cases have been reported of clips that have migrated into the common bile duct, causing stone formation and/or obstructions. We present a case of gallstone pancreatitis treated with laparoscopic cholecystectomy that was complicated by bile leakage from the cystic duct stump 1 day after the procedure. Although the leaking stump sealed itself spontaneously after the placement of a biliary stent, a clip had migrated directly to the superior wall of the first portion of the duodenum. Herein the details of the patient's history are presented. We also discuss the possible mechanisms of clip migration and describe some preventive measures.     

Role of relaparoscopy in the management of minor bile leakage after laparoscopic cholecystectomy

BACKGROUND: Bile leakage in the absence of major ductal injury may occur from the liver bed or from the cystic duct remnant after cholecystectomy. The early limitations of minimally invasive surgery led to reliance on endoscopic methods to manage this complication. However, repeat laparoscopy permits drainage of the bile collection and direct control of the site of leakage in selected situations. METHODS: Details of 15 patients with bile leakage after laparoscopic cholecystectomy were recorded prospectively and are reviewed. RESULTS: Postoperative bile leakage occurred after 15 (0.8 per cent) of 1779 laparoscopic cholecystectomies. Two patients with bile in drainage fluid had spontaneous resolution. Ten patients with a subvesical duct leak had repeat laparoscopy. The leak was successfully controlled by suturing in eight patients, and by a laparoscopically placed drain in two. One patient required a subsequent laparotomy for a loculated pelvic collection. Three patients had cystic duct stump leakage. This was managed successfully by laparoscopy in one case but required endoscopic management in two. CONCLUSION: Laparoscopy is useful in the management of minor bile leaks after laparoscopic cholecystectomy. Selection of appropriate patients relies on a characteristic clinical presentation after an otherwise uncomplicated cholecystectomy.     

Clip migration causes choledocholithiasis after laparoscopic cholecystectomy

The migration of surgical clips after laparoscopic procedures was first reported in 1992, but such instances are extremely rare. We herein demonstrate a case of a migrated metal clip, which had been applied originally to the cystic duct, but thereafter had moved to the common bile duct. This clip caused choledocholithiasis in a patient 1 year after a laparoscopic cholecystectomy. A 63-year-old man underwent a laparoscopic cholecystectomy. During the operation, the inflamed cystic duct was divided accidentally, and three clips were applied immediately. The patient complained of upper abdominal pain from postoperative day 8. Endoscopic retrograde cholangiography demonstrated bile leakage from the cystic duct, but showed no clips or choledochal stones. The patient complained of severe upper abdominal and back pain 1 year after the operation. Endoscopic retrograde cholangiography showed a metal clip in the common bile duct and choledochal stones above the clip. The clip and the cholesterol stones were removed using a basket catheter. Three clips applied to the cystic duct should have been removed because of the necrosis in the remaining cystic duct. Thereafter, the clip may have migrated through the stump of the cystic duct into the lower part of the common bile duct. This clip seems to have later caused choledocholithiasis resulting from stagnation of the bile flow. Bile leakage after an operation seems to increase the risk of clip migration. Regardless of the primary lesion, a careful follow-up evaluation is necessary for patients demonstrating complications.     

Reoperation after cholecystectomy. The role of the cystic duct stump

The so-called "Postcholecystectomy Syndrome" may be due to various pathological biliary causes. The aim of this study was to evaluate the significance of the cystic duct stump syndrome and if so, how often a long (greater than 1.5 cm) cystic duct stump was an indication for reoperation on the bile ducts after cholecystectomy in our patients. Three hundred and twenty two patients underwent a second operation on the bile ducts after cholecystectomy in the last ten years. In 35 patients (10.8%) a striking findings was a long cystic duct stump (greater than 1.5 cm). In 24 of these patients, a pathological finding, in addition to the long cystic duct stump, was found on exploration. Out of these 24 patients there were 14 with common bile duct stones; 6 with stenosis of the sphincter of Oddi; 3 with chronic pancreatitis and in one patient hepatitis was the cause of the symptoms. From the remaining 11 patients 8 had a stone in a partial gall bladder or cystic duct stump. One patient had a fistula between the cystic duct stump and duodenum and one a suture granuloma. There was only one patient where a 1.5 cm long cystic duct stump remnant was the only pathological finding. Four years after reoperation this patient is still suffering from the same intermittent gastrointestinal symptoms. We conclude that the cystic duct stump is hardly ever a cause for recurrent symptoms in itself. Total excision of the cystic duct does not eliminate the existence of postcholecystectomy symptoms.     

腹腔镜胆囊切除术后胆囊管结石残留的预防及处理

目的 探讨腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）术后胆囊管结石残留的预防及处理.方法 回顾性分析自2004年5月至2012年12月间共成功施行4 751例LC的临床资料.结果 135例LC术中采用胆囊管远端紧靠壶腹部施夹钛夹、切开胆囊管、自近端向远端挤压法取出胆囊管结石;其余4 616例中,12例术后发生胆囊管结石残留,4例经再次腹腔镜手术、8例经开腹手术成功取石,未再发生结石残留及其他严重并发症.结论 对胆囊管残余结石高风险病例,LC术中采用切开胆囊管、自近端向远端挤压法是预防术后胆囊管结石残留的有效方法.确诊LC术后胆囊管结石残留,应积极手术治疗,选择合适的病例再次经腹腔镜手术取出结石是安全可行的.     

Bile leakage resulting from clip displacement of the cystic duct stump

We present the case of a patient who underwent successful endoscopic nasobiliary drainage (ENBD) for bile leakage resulting from clip displacement of the cystic duct stump sustained during a laparoscopic cholecystectomy (LC). This 69-year-old man was admitted with symptomatic cholecystolithiasis. After LC was performed, intraoperative cholangiography (IOC) revealed no abnormal findings. However, postoperatively, bilious material began to appear from the intraabdominal drain. Subsequent endoscopic retrograde cholangiopancreatography (ERCP) showed bile leakage from the end of the cystic duct stump. ENBD was performed. Cholangiography using the ENBD tube 14 days later failed to show a bile leak. The ENBD was subsequently removed. The patient improved rapidly with no complaints. Bile leakage due to clip displacement from the cystic duct stump is a potential pitfall of LC, especially if IOC is normal. We recommend careful cystic duct ligation, combined with the use of superior quality ligation clips, to prevent this complication. ENBD is a useful technique to prevent bile leakage after this complication.     

An unusual bile collection after postcholecystectomy bile leakage

Leakage from the cystic duct stumps accounts for the majority of postlaparoscopic cholecystectomy leaks. It commonly presents with a localized bile collection in the gallbladder fossa and endoscopic retrograde cholangiopancreatography (ERCP) with biliary stenting is a common method of treatment. However, bile may collect in other intra-abdominal locations away from the gallbladder fossa. We present here a case of a patient who developed upper abdominal pain with distension, anorexia, and vomiting a week after laparoscopic cholecystectomy. Ultrasonography and computed tomography scans showed an intra-abdominal collection and ERCP showed a cystic duct stump leak. A biliary stent was inserted and the collection was percutaneously drained. His symptoms, however, recurred 2 weeks later, with fever, anorexia, and weight loss. Abdominal computed tomography scan showed 9.3x8.5 cm cystic mass in the left hypochondriac area and ERCP showed persistent leakage from the cystic duct stump. The stent was changed to a larger size Fr12 and the collection was again drained percutaneously. His clinical condition improved dramatically. The biliary stent was removed after 8 weeks and remained well at 9-month follow-up.     

Percutaneous laparoscopic cholecystectomy: indications, contraindications and complications.

The indications, contraindications and complications of percutaneous laparoscopic cholecystectomy (PLC) were established from a group of 308 patients referred for cholecystectomy. Of the 308 patients 86% underwent PLC, 5% were commenced laparoscopically, but converted to open cholecystectomy and 9% were performed as open cholecystectomy from the outset. Complications included two bile leaks from the gall-bladder bed, one cystic duct stump leak and three retained stones. Pre-operative rather than intra-operative duct imaging was used so that common duct stones could be removed before operation. PLC is a safe procedure that has now become the standard technique for cholecystectomy.     

PERCUTANEOUS LAPAROSCOPIC CHOLECYSTECTOMY: INDICATIONS,CONTRAINDICATIONS AND COMPLICATIONS

The indications, contraindications and complications of percutaneous laparoscopic cholecystectomy (PLC) were established from a group of 308 patients referred for cholecystectomy. Of the 308 patients 86% underwent PLC, 5% were commenced laparoscopically, but converted to open cholecystectomy and 9% were performed as open cholecystectomy from the outset. Complications included two bile leaks from the gall-bladder bed, one cystic duct stump leak and three retained stones. Pre-operative rather than intra-operative duct imaging was used so that common duct stones could be removed before operation. PLC is a safe procedure that has now become the standard technique for cholecystectomy.     

简化的腹腔镜胆囊联合阑尾切除术的应用体会

目的:探讨简化的腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)联合腹腔镜阑尾切除术(laparoscopic ap-pendectomy)的可行性及安全性。方法:为42例患者行LC联合LA。术中电凝胆囊动脉、阑尾动脉,胆囊管仅施夹一枚可吸收生物夹,阑尾残端用普迪恩线圈套器套扎。结果:42例手术均顺利完成,均无感染、出血及胆道损伤等并发症发生。手术时间40～70 min,中位55 min;平均住院4 d。结论:术者具有娴熟的腹腔镜手术操作技能、严格掌握联合手术原则与适应证,LC联合LA是快捷可行的,手术安全有效。     

A new bipolar feedback-controlled sealing system for closure of the cystic duct and artery

Background: Bile leaks are serious complications after laparoscopic cholecystectomy. The aim of this study was to evaluate the feasibility of closure of the cystic duct with a new feedback-controlled bipolar sealing system (LigaSure).Methods: Ten domestic pigs underwent open cholecystectomy with the cystic duct and artery dissected and sealed with the new bipolar sealing system (LigaSure). Four and 8 days postoperatively, 5 pigs each were sacrificed and the closure of the cystic duct was evaluated. The cystic stump and the common bile duct were excised for histological examination. Results: None of the pigs had a bile leak or a biliary peritonitis. There were no signs of postoperative bleeding or inflammation in Calot’s triangle. Histology showed total necrosis of the cystic duct in the first two pigs due to too much energy used. The remaining specimens showed a regularly scaling zone without necrosis in 7 cases, and in one case a partial necrosis in the mucosa only was found.Conclusion: Cystic artery and cystic duct closure with the new device may be an alternative to the clip. Further trials should evaluate the feasibility and safety of the new device in the clinical setting.     

Laparoscopic management of remnant cystic duct calculi: a retrospective study

INTRODUCTION

Even though cholecystectomy relieves symptoms in the majority of cases, a significant percentage suffer from ‘postcholecystectomy syndrome’. Cystic duct/gall bladder remnant calculi is a causative factor. We present our experience with the laparoscopic management of cystic duct remnant calculi.

PATIENTS AND METHODS

We managed 15 patients with cystic duct remnant calculi from 1996 to 2007 in our institute. All these patients had earlier undergone laparoscopic subtotal cholecystectomy at our centre. They were successfully managed by laparoscopic excision of the remnant.

RESULTS

The mean duration between first and second surgery was 8.35 months (range, 6–10.7 months). The mean operating time was 103.5 min (range, 75–132 min). Duration of hospital stay was 4–12 days. There was a higher incidence of remnant duct calculi following laparoscopic subtotal cholecystectomy than conventional laparoscopic cholecystectomy 13/310 (4.19%) versus 2/9590 (0.02%). The morbidity was 13.33%, while there were no conversions and no mortality.

CONCLUSIONS

Leaving behind a cystic duct stump for too long predisposes stone formation, while dissecting too close to the common bile duct and right hepatic artery in acute inflammatory conditions is dangerous. We believe that the former is a wiser policy to follow, as cystic duct remnant calculi are easier to manage than common bile duct or vessel injury. Laparoscopic excision of the remnant is effective, especially when performed by experienced laparoscopists. ‘T’-tube is used to canulate the common bile duct in case the tissue is friable. Magnetic resonance cholangiopancreaticography is the imaging modality of choice, and is mandatory.     

腹腔镜胆囊切除术胆道损伤后再手术时机和术式选择

目的探讨腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)致胆管损伤的手术时机、手术方式和技巧。方法回顾12例LC后胆管损伤病例,术中发现2例,术后发现10例。胆囊床小胆管损伤1例,胆囊管残端胆漏1例,肝总管胆总管侧壁撕裂、部分剪断9例,肝总管离断1例。结果本组1例术中胆总管侧壁撕裂损伤,经中转开腹行胆总管修补和T管引流而治愈;术后2例出现胆漏,经充分引流后自愈;1例术后2 d行胆总管修补T管引流者术后发生胆管狭窄及胆道炎症,于1年后行胆管空肠Roux-en-Y吻合术后治愈;其余8例均经胆肠吻合术治愈。随访1.5~5年,无胆道狭窄及胆管炎发作。结论手术仍是LC致胆管损伤的首选治疗方法。把握手术时机避免盲目自信,及早选择有经验的专科医生恰当处理是提高治愈率的关键。