腹腔镜肝切除联合胆道镜治疗肝内外胆管结石36例

目的探讨腹腔镜肝切除联合胆道镜治疗肝内外胆管结石的可行性和安全性。方法 2012年7月~2015年6月采用腹腔镜肝切除联合胆道镜治疗36例左肝内胆管结石,其中合并胆总管结石11例,胆囊结石12例。采用腹腔镜肝左外叶或左半肝切除,均经左肝管残端插入电子胆道镜探查肝外胆管和右肝管,取出肝外胆管结石,缝合左肝断面胆管,不放置T管。结果 36例手术均获得成功,其中腹腔镜肝左外叶切除24例,左半肝切除12例,联合胆囊切除12例。手术时间130~180 min,平均148 min;术中出血量90~350 ml,平均190 ml。术后住院6~14 d,平均9 d。术后1例胆漏内镜逆行胰胆管造影检查后,胆总管内放置胆道支架减压引流,带引流管出院,术后28 d拔除引流管治愈。36例随访6~42个月,平均22个月,优30例,良6例,未见结石残留、复发。结论腹腔镜左肝切除、经左肝管残端胆道镜取石,不放置T管,有利于加速患者康复,缩短住院时间,是可供选择的手术方式。     

完全腹腔镜肝切除术中顺行胆道镜检查的临床应用

目的介绍完全腹腔镜肝切除术中顺行胆道镜检查治疗肝胆管结石的技术要点，初步探讨其临床应用价值。方法2002年6月至2005年12月，11例左肝内胆管结石患者在我科行腹腔镜肝切除术，术中经左肝管残端置入胆道镜探查胆总管及右肝管，根据结果行取石、胆道冲洗治疗，术后封闭左肝管残端。结果11例均成功行完全腹腔镜肝切除术，其中左外叶切除术6例（联合胆囊切除3例），左半肝切除术5例（联合胆囊切除1例）。术中应用胆道镜行单纯胆道冲洗5例，胆总管取石3例，右肝管取石2例，1例因探查发现右肝管开口狭窄而中转行胆管成形术。手术时间（201．4±57．5）min，出血量（136．4±68．6）ml，其中胆道镜探查时间（42．3±12．1）min。术后住院时间（4．6±1．6）d。术后随访（22．5±11．6）个月，优9例，良2例。结论腹腔镜下顺行胆道镜可以不放置T管，从而缩短恢复时间，减轻患者痛苦，是一项安全、可行的技术。     

腹腔镜肝切除治疗肝内胆管结石的临床研究

目的探讨腹腔镜肝切除治疗肝内胆管结石的可行性。方法8例肝内胆管结石患者均在腹腔镜下行胆囊切除胆总管切开胆道镜取石、T管引流,其中7例同时行腹腔镜左肝外叶切除,1例行左半肝切除。结果8例手术均获成功,手术时间(285.00±37.42)min;术中出血(306.25±29.73)mL,手术后无并发症,住院时间(7.88±1.36)d;残石率0。结论腹腔镜肝叶切除治疗肝胆管结石疗效好、安全,联合胆道镜取石疗效更佳。     

胃毕Ⅱ式术后患者肝内外胆管结石的腹腔镜及胆道镜治疗

目的探讨胃毕Ⅱ式术后肝内外胆管结石的腹腔镜及胆道镜治疗。方法对78例胃毕Ⅱ式术后的患者进行腹腔镜胆囊切除32例,其中胆囊切除 胆总管切开取石 胆总管一期缝合12例;胆囊切除 胆总管切开取石 T管引流22例;胆囊切除 胆总管切开取石T管引流 胆总管十二指肠吻合术6例;胆总管切开取石T管引流 左肝外叶切除6例。结果除4例中转开腹外,74例获成功。内镜及腹腔镜术治疗无严重并发症。手术时间为90～240(平均135)min,住院天数4～12(平均9.3)d,术中出血50～400(平均95)ml。随访14～22个月,平均19.4个月,无结石复发。结论胃毕Ⅱ式术后肝内外胆管结石者施行腹腔镜及胆道镜治疗成功率较高,具有微创、住院时间短、恢复快等优点。     

腹腔镜肝左外叶切除联合胆道镜治疗肝左外叶为主的结石23例

目的探讨腹腔镜肝左外叶切除联合术中应用胆道镜在治疗肝左外叶肝内胆管结石中的可行性及安全性。方法 2014年11月至2016年10月对23例肝左外叶为主的肝内胆管结石病人行腹腔镜肝左外叶切除联合胆道镜检查及取石,其中9例病人合并胆总管结石,合并胆囊结石11例,同时合并胆总管结石及胆囊结石7例,合并肝左内叶结石3例。结果 23例病人均成功行腹腔镜下肝左外叶切除,并通过肝断面胆管经胆道镜对肝内胆管及胆总管检查、取石,9例病人通过胆道镜取出胆总管内结石,11例病人联合胆囊切除,3例病人通过胆道镜取出肝左内叶结石。所有病人手术顺利,手术时间为142~188 min,平均(157±27)min;术中出血量为150~550 ml,平均(240±52)ml;胃肠功能恢复时间为1~3 d,平均(1.7±0.6)d;术后住院时间为7~13 d,平均(9.0±2.2)d。术后1例病人发生肝断面渗血,2例病人发生胆漏,均经保守治疗治愈。术后随访病人3~24个月,均未见结石残留及复发。结论腹腔镜肝左外叶切除联合术中应用胆道镜治疗肝左外叶肝内胆管结石具有疼痛轻、恢复快、残石率低的优势,是一种安全、可行的手术方式,可在临床中广泛应用。     

腹腔镜下经纤维胆道镜治疗肝内外胆管结石的体会(附730例报告)

目的:探讨腹腔镜联合纤维胆道镜及液电碎石术治疗肝内、外胆管结石的临床应用价值。方法:回顾分析730例腹腔镜胆道手术中经胆囊管残端、胆总管切开及术后经"T"管窦道行纤维胆道镜下取石、液电脉冲碎石的临床资料。结果:346例一次性取净胆总管内结石,占47.4%;31例一次性取净左、右肝内胆管结石,占19.5%。术后经"T"管窦道纤维胆道镜取石、液电碎石治疗后全部治愈。术后胆漏3例,出血17例,无死亡病例及中转开腹。结论:腹腔镜联合纤维胆道镜、液电碎石术治疗肝内、外胆管结石符合微创、安全、可靠、有效的原则,腹腔镜下纤维胆道镜操作技术是治疗肝内、外胆管结石的关键。     

130例肝内胆管结石治疗分析

对130例肝内胆管结石病例，行左肝部分切除结合胆总管切开取石51例，死亡2例，残石5例，残石率10％；行单纯胆总管切开取石69例，死亡1例，残石22例，残石率31％。对23例残石患者术后1个月经T管隧道行纤维胆道镜取石，清除残石12例。认为单纯经胆总管切开取石有易于手术操作，创伤小，手术并发症及死亡率较低等优点，但残石率高；而高位胆管切开结合左肝外叶切除取石是治疗肝内结石的较好手术方法，术后胆道镜取石是治疗残石的重要的补救措施。     

老年肝内外胆管结石的腹腔镜手术治疗

目的　探讨老年肝内外胆管结石的腹腔镜手术的可行性和特点。方法　 2 0 0 2年 1月至 2 0 0 3年 1月应用腹腔镜胆总管切开纤维胆道镜取石治疗老年肝内外胆管结石 2 0例 ,取石后胆总管均置T管引流。结果　 2 0例手术均获成功 ,术后 1例肝内胆管残余结石 ,术后 6周经T管窦道纤维胆道镜取石治愈 ,1例 16d拔T管后胆汁性腹膜炎 ,开腹引流后治愈。结论　老年肝内外胆管结石腹腔镜手术创伤小 ,安全 ,疗效满意。     

腹腔镜肝叶切除联合胆道镜治疗肝内外胆管结石的临床研究

目的:探讨腹腔镜左肝叶切除并联合胆道镜行胆总管探查取石的可行性、安全性及效果。方法:回顾分析2009年6月至2012年1月为45例左肝内胆管结石合并胆总管结石患者行腹腔镜左肝叶切除联合胆道镜胆总管切开取石术的临床资料。结果:45例手术均顺利完成。手术时间126～185 min,平均(145±47)min;术中出血量120～450 ml,平均(210±63)ml。术后4例发生胆漏。结论:腹腔镜左肝叶切除联合胆道镜行胆总管探查取石术是安全、有效的。     

腹腔镜肝切除术治疗左肝内胆管结石的临床应用

目的 探讨腹腔镜肝切除术治疗左肝内胆管结石的技术与疗效。 方法 回顾性分析2011年1月至2016年12月完成67例腹腔镜肝切除术治疗左肝内胆管结石临床及随访资料。 结果 全部67例患者合并左半肝或左外叶肝萎缩,腔镜手术方式包括左外叶肝切除48例、左半肝切除19例。其他腹腔镜下联合术式包括：胆囊切除术52例、胆总管探查术43例、T管引流术39例,胆总管一期修补术4例。手术切口长度（4.67±1.26）cm。术后发生胆漏3例,均经引流观察后自愈;1例因术后腹腔大出血合并胆瘘再手术治愈;肝脓肿1例,膈下脓肿1例,均经穿刺引流治愈。 结论 腹腔镜肝切除术治疗左肝内胆管结石安全可靠,术中应尽量取净其他胆道残余结石并连续紧密缝合左肝管残端。如结石已被取净胆总管的探查和T管引流并非必需。     

Intraoperative biliary exploration through the left hepatic duct orifice during left hepatectomy in patients with left-sided hepatolithiasis

Background and aims Left-sided hepatolithiasis often requires left hepatectomy and exploration of the common bile duct and right hepatic duct. The aim of this study was to assess the feasibility of alternative method of bile duct exploration other than choledochotomy. Materials and methods A prospective study involving 50 cases of left hepatectomy for left or bilateral intrahepatic stone was performed. Left hepatic duct (LHD) orifice was used as primary access route for biliary exploration. Choledochotomy was performed only for large common bile duct stones, variant bile duct anatomy, or intentional T-tube insertion for later removal of residual stones. Results In 44 patients with left-sided hepatolithiasis, biliary exploration through LHD orifice was performed in 40 (90.9%); T-tube choledochotomy was required in three (9.1%). There was neither residual stone nor major surgical complication except infection, and recurrence occurred in one patient during mean follow-up of 32 months. On the other hand, T-tube choledochotomy was performed in three of six patients with bilateral hepatolithiasis (50%). Three patients had residual stones, and two of them were treated by cholangioscopy through the T-tube tract. Recurrence occurred in two patients. Conclusion We think that intraoperative biliary exploration through LHD orifice in left-sided hepatolithiasis patients is an effective approach simplifying the operation procedure by avoiding choledochotomy and subsequent T-tube insertion.     

肝内胆管结石外科手术方法探讨

目的: 探讨肝内胆管结石并狭窄的手术治疗方法及其效果。方法: 总结8年间住院的165例肝内胆管结石并胆管狭窄患者的外科手术治疗情况。其中A组85例行肝叶(或肝段)切除的各种术式，同时行胆管空肠吻合40例，肝断面扩张胆管、肝门胆管与空肠双口吻合10例，T管和U管引流分别为21例和14例；B组80例行非肝叶(或肝段)切除术的各种术式，其中胆总管切开取石+T管引流23例，胆总管切开取石+U形管引流15例，胆肠吻合+胆总管取石42例。肝门部肝胆管狭窄整形46例。结果: A组无手术死亡；随访2～7年，术后残留结石4例，残石率4.71%；症状复发3例，复发率3.53%，无再手术者。B组无手术死亡；B组随访2～7年，术后残留结石12例，残石率15.00%。10例术后常有上腹隐痛或发热，症状复发率12.5%。术后经胆道镜取石5例，其余6例中有3例再次行肝叶切除治愈。结论: 肝段(叶)切除联合其他手术是治疗肝内胆管结石较为理想而有效的手术方式。     

Obstructive jaundice caused by tumor emboli from hepatocellular carcinoma

Hepatocellular carcinoma (HCC) presenting as obstructive jaundice due to intrabile duct tumor growth is being reported with increasing frequency. We describe our clinical experiences and evaluate the results of different operative procedures for this disease. A retrospective study was undertaken to review 18 patients with obstructive jaundice by tumor emboli from HCC during a 15-year period of time. We reviewed clinical features, types of operative procedures, operative findings, and survival in the patients. All patients on initial examination had recurrent episodic jaundice or cholangitis. Types of surgical procedures were choledochotomy with T-tube drainage alone in nine patients, choledochotomy with T-tube drainage followed by hepatectomy in six, and T-tube drainage followed by transcatheter hepatic arterial chemoembolization in the remaining three patients. Liver cirrhosis was the associated disease in 15 (83.3%). There were three postoperative deaths (16.7%). The mean survival time for nine patients with external drainage alone was 4.5 months. For the three patients with T-tube drainage and transcatheter hepatic arterial chemoembolization, mean survival time was 11 months. Six patients who had undergone hepatectomy had a better postoperative survival time, with 1 surviving for more than 3 years and another alive for 70 months, without evidence of recurrence at the moment. Jaundice is not necessarily a harbinger of advanced disease and a contraindication for surgery. Managed properly, these patients will have satisfactory palliation and occasional cure.     

腹腔镜肝切除术在肝内胆管结石治疗中的应用

目的探讨腹腔镜肝切除术在肝内胆管结石治疗中的应用价值。方法回顾性分析笔者所在医院2003年11月至2012年11月期间采用腹腔镜肝切除术治疗的35例肝内胆管结石患者的临床资料。手术方式包括腹腔镜肝左外叶切除、左半肝切除、胆囊切除、胆总管切开探查取石、胆道镜探查取石、T管引流等。结果 35例患者的手术均完全在腹腔镜下完成,平均手术时间为205 min（150～370 min）,术中平均出血量为330 mL（50～1 000 mL）。术后患者痛苦轻,均未用止痛药。术后1 d即可下床活动,2 d恢复流质饮食,术平均后住院时间为12.3 d（4～15 d）。无死亡病例;手术优、良率分别为71.4%和25.7%。结论选择合适的病例,腹腔镜肝切除术治疗肝内胆管结石是一项微创、有效的可供选择的治疗方法之一。     

腹腔镜胆道探查术胆管一期缝合与T管引流的疗效比较

目的 比较腹腔镜胆道探查术胆管一期缝合与T 管引流两种方法治疗胆囊结石继发胆总管结石患者的疗效.方法 根据腹腔镜胆管探查取石的胆总管内是否放置T管引流,将85例因胆囊结石继发胆总管结石患者分为一期缝合组和T管引流组,比较两组的手术和住院时间、输液量、住院费用、术后恢复情况及手术并发症等.结果 一期缝合组较T管引流组的手术时间及术后住院时间更短、恢复正常工作更快、输液量和住院费用更少(P<0.05),两组手术并发症差异无统计学意义(P>0.05),均无再次手术.结论 腹腔镜胆管探查取石胆管一期缝合避免了放置T 管引起的一系列弊端,体现出微创技术的优越性,治疗适合的胆囊结石继发胆总管结石患者是安全可行的.     

腹腔镜胆总管切开取石一期缝合术(附29例报告)

目的:探讨腹腔镜胆总管切开取石一期缝合术的优点、方法及适应证。方法:应用腹腔镜手术设备及纤维胆道镜为29例胆总管结石患者行腹腔镜胆总管切开取石术,不置T管引流,一期缝合胆总管壁。结果:26例手术成功,平均手术时间98.2m in,术中平均出血15.3m l,术后平均肛门排气时间19.6h,术后平均住院8.3d,无胆漏等严重并发症发生,3例中转行腹腔镜胆总管切开取石T管引流术。结论:应用腹腔镜胆总管切开取石一期缝合术治疗胆管结石具有创伤小、住院时间短及并发症少的优势,对符合适应证的患者是一种安全、有效的术式,但应掌握操作技巧以提高手术成功率、防止胆漏的发生。     

腹腔镜胆总管切开取石术T管处理的探讨

目的探讨腹腔镜胆总管切开取石术后T管的处理方法。方法1997年7月-2004年10月，我院行腹腔镜胆总管切开取石（laparoscopic common bile duct exploration，LCBDE）、置T管治疗肝外或肝外合并肝内胆管结石420例。明确有胆总管结石后，胆总管切开取石，胆总管一期缝合或置T管。结果胆总管切开取石一期缝合27例（6．4％），置T管393例（93．6％）。术中取尽结石236例（56．2％），术后胆道镜取石184例（43．8％）。209例术后3-4周行经T管胆道造影，无残余结石，拔除T型管。420例随访3个月-6年。平均47．5月，3例复发。结论腹腔镜胆总管切开取石术后T管拔管时间，T管造影无残留结石拔管时间应3—4周，T管造影有残留结石，应于术后6周胆道镜取石后拔管，均闭管2周。     

Common bile duct exploration--primary closure of the duct with retrograde transhepatic biliary drainage

A new method of retrograde transhepatic biliary drainage (RTBD) using an RTBD tube with primary closure of the common duct was investigated with special reference to the usefulness and feasibility of this procedure. At operation, an atraumatic vinyl chloride tube was inserted from a choledochotomy incision and in most cases advanced via the left hepatic duct to the liver surface, which was then penetrated. After the choledochotomy incision had been primarily sutured, the RTBD tube was fixed to the abdominal wall. This drainage method was applied to 71 patients as an alternative to the conventional T-tube drainage and its effect on bile drainage was prominent. The insertion of an RTBD tube did not influence liver function tests and an RTBD tube cholangiography revealed no severe deformity at the primary closure site of the bile duct. The most common complication was movement of the optimal site for stenting of the bile duct, however, no serious complications were encountered. On average, the RTBD tube was removed on the 16th postoperative day, the mean postoperative stay in hospital being 22 days. These findings suggest the need for a prospective randomized clinical trial to prove the usefulness and feasibility of primary bile duct closure using our drainage method.     

腹腔镜联合胆道镜行胆总管切开取石探查术156例临床体会

目的:总结腹腔镜联合胆道镜行胆总管切开探查取石、T管引流术的临床体会。方法:先行腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC),再切开胆总管,用特制的腹腔镜胆总管取石钳取石,胆道镜主要观察胆总管及肝内外胆管有无结石残余及是否通畅,必要时经胆道镜取石。结果:术后拔T管时出现胆漏3例,1例术后10d T管自胆总管脱出至腹腔,1例术后24h胆漏达400ml,6例中转开腹,余均痊愈出院,无残石及术后胆管狭窄等并发症发生。结论:腹腔镜联合胆道镜行胆囊切除、胆总管切开探查取石、T管引流术具有安全可靠、患者损伤小、康复快、住院时间短等优点,是治疗胆囊结石、胆总管结石的有效术式。