腹腔镜胆囊切除术中胆管损伤的预防

目的总结腹腔镜胆囊切除术中胆管损伤的原因及其防治方法. 方法回顾分析1 000例腹腔镜胆囊切除术临床资料. 结果中转开腹手术15例(1.5%);并发症6例(0.6%),其中胆总管损伤3例,胃穿刺损伤1例,腹壁刺口出血1例,胆漏1例.无远期并发症. 结论胆道牵拉成角是胆管损伤最常见原因.     

腹腔镜胆囊切除术胆道并发症的防治

目的:探讨腹腔镜胆囊切除术(LC)胆道损伤的预防策略。方法:采用回顾性分析方法,从HIS系统中检索2010～2018年收治的胆道损伤患者,出院诊断中检索"胆道损伤"、"胆管损伤"、"胆漏(瘘)",剔除各种原因行胆肠吻合术后胆漏、外伤术后胆漏、胆道损伤后施行手术再次胆道狭窄等。按最常用的胆道损伤分型(Straberg)进行分型。结果:通过以上检索策略,共检索出24例LC术后胆道并发症患者,其中由外院转入20例,本院4例。2010～2018年分别为3、2、2、3、2、3、2、2、5例。其中男6例,女18例;26～74岁。按Straberg分型,A型3例,B型0例,C型3例,D型1例,E型17例。在E型中,E1型4例,E2型4例,E3型5例,E4型3例,E5型1例,其比例分别为12.5%、0、12.5%、4.2%、16.7%、16.7%、20.8%、12.5%与4.2%。经积极处理,患者均获得良好效果出院。结论:医源性胆道损伤最常见于LC术中,预防是关键。胆道损伤后,根据损伤方式、类型选择恰当的时机与方式可获得良好效果,提高患者的生活质量。     

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。     

腹腔镜胆囊切除术中医源性胆道损伤的处理策略

目的:探讨腹腔镜胆囊切除术(LC)中医源性胆管损伤的诊断及处理策略。方法:回顾分析2009年1月至2018年12月19例LC导致的医源性胆管损伤患者的临床资料。按Strasberg-Bismuth胆管损伤分型,胆囊管残端漏或胆囊床小胆管漏(A型)3例(15.8%);副右肝管损伤导致胆漏(C型)2例(10.5%);肝外胆管侧壁损伤导致胆漏(D型)7例(36.8%);肝外胆管横断损伤导致胆管梗阻(E型)7例(36.8%)。术后发现并处理7例,其中行胆管空肠Roux-en-Y吻合治疗4例,行内镜鼻胆管引流、腹腔引流3例。术中发现并处理12例,其中腹腔镜胆管修补1例,腹腔镜胆管修补+T管引流3例,腹腔镜胆囊床小胆管夹闭处理2例,中转开腹行胆管空肠Roux-en-Y吻合3例,胆管端-端吻合+T管引流1例,副右肝管空肠Roux-en-Y吻合2例。结果:19例患者失访2例,随访率89.5%,术后中位随访时间49个月。1例患者经过内镜鼻胆管引流、腹腔引流后胆漏消失,但拔管后出现胆管狭窄、黄疸,于术后5个月再次行胆管空肠Roux-en-Y吻合治愈。全组均无严重并发症及死亡病例。结论:LC相关医源性胆管损伤应根据损伤发现时间、原因、部位及程度等因素进行个体化治疗,及时诊断并由经验丰富的专科医师进行确定性修复手术是改善预后的关键。     

胆囊切除术相关胆管损伤手术修复的临床分析

目的探讨胆囊切除相关医源性胆管损伤的原因、临床分型、手术修复的预后,为临床治疗提供参考。方法回顾性分析安徽医科大学第一医附属医院2004年1月～2015年12月收治的31例胆囊切除术导致医源性胆管损伤行手术修复治疗的患者临床资料,电话随访预后。结果 31例患者年龄M (P25, P75)为44 (37, 57)岁,男性11人,女性20人。行开放胆囊切除术11人,行腹腔镜下胆囊切除术20人(laparoscopic cholecystectomy,LC)。4例在行胆囊切除术中发现胆管损伤;非术中发现胆管损伤的27例患者中21例首发症状表现为黄疸,19例在行内引流手术前明确受伤部位。中华医学会胆道损伤临床分型:Ⅱ1、Ⅱ2、Ⅱ3的比例分别是74.2%、22.6%、3.2%;临床分类:a、b、c、d的比例分别是35.5、9.7、35.5、19.3;2例合并血管损伤。即时处理、早期处理(≤2周)、延迟处理(2周)的比例分别是12.9%、19.4%、67.7%。干预方式上胆总管端端吻合、桥式内引流+Y管外引流、胆管-空肠Roux-en-Y吻合、胆管-空肠Roux-en-Y吻合+外引流管置入的比例分别是3.2%、3.2%、25.8%、67.7%。修复术后30天内并发症(Clavien-Dindo Classification≥3)发生率是35.5%,长期并发症发生率是41.9%。延期修复术后胆肠吻合口漏的发生率显著低于即时修复(P=0.043),延期手术的围手术期并发症(Clavien-Dindo Classification≥3)的发生率明显低于即时手术和早期手术组(P值分别为0.017、0.044),但三者间的胆肠吻合口狭窄的发生率无明显差异。单因素分析显示存在胆管组织缺损的胆管损伤是远期胆管炎反复发作的预测因素。结论胆肠吻合是一种相对安全的治疗胆道损伤的手术方式,延期手术可能有利于患者的预后,胆囊切除相关医源性胆道损伤中存在胆管组织缺损的损伤类型与修复手术后远期发生胆管炎反复发作明显相关,行确定性修复手术应注意胆管的整形。     

胆囊切除术胆道损伤20例的Strasberg分型、处理与预后

目的探讨胆囊切除术致胆道损伤的Strasberg分型、处理与预后的关系。方法回顾性分析近8年间收治的胆囊切除术后胆道损伤病人的临床资料和Strasberg分型。结果按胆道损伤Strasberg分型标准，20例中A型7例，非手术治疗有效，恢复良好；D型4例，均为术中发现，行胆管修补，随访良好；E1型1例，术后外引流，3个月后择期行胆肠吻合术，随访良好；E2型2例，术中发现，行胆肠吻合术，随访良好；E3型3例，其中1例术中行肝胆管空肠吻合术，随访良好，另2例3个月后择期行胆肠吻合术，1例恢复不良；E4型3例，均择期行胆肠吻合，1例恢复不良。结论胆囊切除术致胆道损伤疗效取决于损伤的类型，术中、术后正确处理，以及专科医生参与。     

腹腔镜胆囊三角V型解剖临床应用

目的 探讨腹腔镜胆囊三角解剖的最佳手术捷径.方法 采用回顾性分析法.在我中心18726例胆囊三角后侧入路解剖,与2968例胆囊三角V型解剖入路、术后并发症进行分析.结果 腹腔镜胆囊三角后侧入路组,术中胆道损伤28例(0.15%),胆漏62例(0.33%),胆囊三角V型解剖组,胆道损伤1例,胆漏3例(0.1%)两者统计学处理有非常显著差异(P<0.01).结论 腹腔镜胆囊切除采用胆囊三角V型解剖是目前最佳手术方法.     

ERCP在医源性胆管损伤中的治疗价值(附117例报告)

目的探讨内镜逆行胰胆管造影(ERCP)技术在医源性胆管损伤中的应用价值。方法回顾性分析2007年1月至2016年8月兰州大学第一医院普外二科收治的医源性胆管损伤并行ERCP治疗的病人117例临床资料,分析ERCP治疗不同Strasberg分型胆管损伤的临床效果。结果 117例胆管损伤病人均实施ERCP治疗,其中Strasberg分型A型56例,C型10例,D型17例,E型34例(E1型13例、E2型10例、E3型5例、E4型6例),87例(74.4%,87/117)病人行ERCP治疗效果良好。ERCP治疗方案为鼻胆管引流、胆道塑料支架或金属覆膜支架联合应用。术后随访1年,A型有效率为100%(56/56),C型有效率为33.3%(3/10),D型有效率94.1%(16/17),E型总有效率为35.3%(12/34)。30例病人内镜治疗未获成功,经经皮肝穿刺胆管引流(PTCD)后转外科手术治疗。87例病人成功实施ERCP病例中,7例术后发生急性胆管炎,6例发生急性胰腺炎,均经保守治疗痊愈,无其他并发症发生。结论 ERCP对胆漏型胆管损伤中Strasberg分型A、D型病人疗效好,对于合并副右肝管损伤的C型病人疗效欠佳;而对于部分Strasberg E3、E4型的高位狭窄及少数E1、E2型严重狭窄的病人,ERCP疗效有待提高。     

腹腔镜下处理腹腔镜胆囊切除术胆道和胃肠道损伤

目的评价腹腔镜下处理腹腔镜胆囊切除术后胆道和胃肠道损伤. 方法 1991年10月～2002年12月,完成连续无选择腹腔镜胆囊切除术和腹腔镜胆囊切除联合胆道探查9 016例,其中发生胆道损伤14例(0.15%),胃肠道损伤3例(0.03%).其中1例胆管横断伤、10例胆管部分损伤、1例胃损伤、2例十二指肠损伤均在腹腔镜下修补. 结果 1例胆道损伤腹腔镜下修补术后胆漏,1年后发生胆道狭窄,其余均痊愈出院. 结论胆道部分损伤及胃肠道损伤可在腹腔镜下处理,对于胆道横断伤的腹腔镜处理,需进一步探讨.     

腹腔镜胆囊切除术并发症的处理

目的：探讨腹腔镜胆囊切除术(LC)并发症发生的原因、预防及处理方式。方法：回顾分析本院1996年5月—2002年3月腹腔镜胆囊切除术的临床资料，研究并发症发生的原因及处理方式。结果：本组比1414例，中转开腹(包括延期开腹)68例，中转率为4．9％。胆道损伤6例(占0．42％)中行肝外胆管切开T管外引流2例(包括肝外胆管修补1例)，单纯性腹腔引流1例，胆肠Roux-Y吻合2例(其中行肝方叶切除、肝门部胆管整形1例)，胆囊管缝扎 腹腔引流1例。腹腔内出血6例(占0．42％)中延期开腹缝扎止血2例。结论：①严格掌握LC的手术适应证，及时中转开腹是避免LC手术并发症的重要途径。②胆肠Roux-Y吻合术、腹腔引流仍是目前处理LC术后胆道损伤的主要术式。③预防性腹腔引流可避免部分病例再手术。     

Iatrogenic biliary injury: 13,305 cholecystectomies experienced by a single surgical team over more than 13 years

Background Biliary injuries during laparoscopic cholecystectomy (LC) are complications better avoided than treated. These injuries cause long-lasting morbidity and can be fatal. The authors present their experience with biliary injury in LC during a period exceeding 13 years. Methods Between January 1992 and December 2005, 13,305 LCs were performed at the authors’ institution. The biliary injuries in these cases were recorded and analyzed retrospectively. Results A total of 52 biliary injuries were identified in 13,305 LCs, for an overall incidence of 0.39%. Of these, 32 (0.24%) were diagnosed intraoperatively and 20 (0.15%) were diagnosed postoperatively. The perioperative bile duct injuries (BDIs) included 6 complete transections (5 treated by hepaticojejunostomy and 1 by primary T-tube repair (TTR), all performed by conversion to open procedure), 11 lateral BDIs (2 treated by laparoscopic choledochojejunostomy [CJ], 1 by open CJ, 5 by laparoscopic TTR, 1 by open TTR, and 2 by primary suture repair, both performed laparoscopically), 11 duct of Luschka injuries, and 4 sectoral duct injuries. The BDIs detected postoperatively included 6 patients with bilioma (treated with ultrasonography-guided aspiration), 4 patients with biliary peritonitis (requiring relaparoscopy and peritoneal lavage and drainage followed by endoscopic retrograde cholangiography [ERC] and biliary stenting), and 10 patients with persistent biliary leak-controlled biliary fistula (requiring ERC and stenting). There was no mortality related to BDI in the series. Patients with Strasberg type A/C/D injuries (46 cases) were followed 3 months to 3 years with no major complaints. Two patients with complete transection were lost to follow-up evaluation, whereas the other four patients, followed 18 months to 3 years, were asymptomatic. Conclusions According to the findings, LC is a safe procedure with an incidence of biliary injury comparable with that for open cholecystectomy. Single-center studies such as this are important to ensure that standards of surgery are maintained in the community.     

Laparoscopic bile duct injuries: spectrum at a tertiary-care center

BACKGROUND and PURPOSE: Laparoscopic cholecystectomy (LC) is associated with a higher incidence of bile duct injury than is open cholecystectomy. We reviewed our experiences with the management of laparoscopic bile duct injuries. PATIENTS and METHODS: From October 1992 through August 1998, 34 patients with bile duct injuries (BDI) following LC were seen. The presentation, type of injury (Strasberg classification), management, and outcome were analyzed in these patients. RESULTS: Of the 16 patients who sustained injury at our center (type A [N = 9], D [N = 5], and E1 [N = 2]), in 14, the injury was detected during LC, and two patients manifested with postoperative bile leak. All patients had an excellent outcome at a median follow-up of 5.5 (range 1.9-8.0) years. Of the 18 patients who sustained injury elsewhere (type C [N = 1], D [N = 2], E [N = 14; 6 with external biliary fistula (EBF) and 8 with benign biliary stricture (BBS)], and not known [1]), 9 had EBF, 1 had biliary peritonitis, and 8 had BBS at the time of presentation. Of these 18 patients, 4 underwent early repair of the BDI before referral (repair over a T-tube [N = 2] and Roux-Y hepaticojejunostomy [N = 2]). Three of them developed restricture. One patient was referred to us within 12 hours of injury and had a successful repair over a T-tube. Two patients with early repair for lateral injury had an excellent outcome. Eleven patients with BBS underwent repair with an excellent (N = 10) or fair (N = 1) outcome at a median follow-up of 5.0 (2.0-6.2) years. Three patients were lost to follow-up. CONCLUSION: The spectrum of injuries sustained at LC at a tertiary-care center is different from that in the community hospitals. Missed injuries and attempts at repair in inexperienced hands result in serious sequelae of stricture formation and long-term morbidity.     

Outcome of surgery for bile duct injuries following laparoscopic cholecystectomy: Lahore General Hospital experience

The objective of this study was to describe the management and outcome of repair in patients who sustained bile duct injuries (BDI) following laparoscopic cholecystectomy (LC). This study was conducted in the department of surgery, Postgraduate Medical Institute/Lahore General Hospital, Lahore, over a period of 5 years from April 1999 to March 2004. Twelve patients of BDI following LC were managed during this period. Three out of 725 patients (0.4%) sustained BDI during LC in our own hospital, while 9 (75%) patients were referred from elsewhere. Strasberg type E accounted for majority of the injuries (66.6%). In 8 patients, Roux-en-Y hepaticojejunostomy was done. Excellent outcome after surgical reconstruction of BDI was noticed in 11(91%) patients.     

腹腔镜胆囊切除术胆管横断性损伤的原因及对策

目的：探讨腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）致胆管损伤的特点及处理方法。方法：回顾总结3例LC术中胆管横断伤的临床资料,分析3例胆管横断性损伤的原因及对策。结果：胆管横断性损伤3例,术中发现1例,术后发现2例;胆管修补（端端吻合）＋T管支撑引流1例,胆肠Roux-en-Y吻合2例。结论：规范腹腔镜医师培训,提高腹腔镜操作技术,严把手术质量关,避免盲目自信,重视解剖变异、病理性异常,及时中转手术是预防胆道损伤的关键。     

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。     

SURGISIS-assisted surgical site control in the delayed repair of a complex bile duct injury after laparoscopic cholecystectomy

Although laparoscopic cholecystectomy has revolutionized the surgical approach to patients with gallbladder disease, it has also brought a marked increase in the incidence of complex and serious bile duct injuries. Many of these major injuries represent a major technical challenge for even the most seasoned hepatobiliary-trained surgeon. Herein, we present a case outlining the algorithmic treatment approach for delayed-presentation complex biliary injury and report on the novel use of small intestinal submucosal biomaterial for surgical site control in the staged repair of a complex biliary injury (Strasberg E₄) after laparoscopic cholecystectomy. Presented at the Fifth Biennial Meeting of the American Hepato-Pancreato-Biliary Association, Fort Lauderdale, Florida, April 14–17, 2005.     

腹腔镜胆囊切除胆道损伤后再手术时机和选择

目的探讨腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）致胆管损伤（bileduct injury,BDI）的手术时机、手术方式及技巧。方法回顾性分析我院收治的21例接受手术治疗的LC后胆管损伤病例,胆管损伤Ⅰ型2例、Ⅱ型11例、Ⅲ型仅2例、Ⅳ型6例。结果本组1例术中Ⅱ型胆总管损伤,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。术后随访1.5～5年,无胆道狭窄及胆管炎发作。其余20例均接受了毁损的胆管切除、肝总管或左右肝管的胆肠吻合术,并获得治愈。结论LC致BDI手术仍是BDI的首选治疗。把握手术时机,避免盲目手术,及早选择有经验的专科肝胆外科医生恰当处理是提高治愈率的关键。     

单中心腹腔镜胆囊切除术预防胆管损伤的体会

目的:探讨如何预防腹腔镜胆囊切除术(LC)胆管损伤。方法:回顾分析37 781例LC的临床资料。结果:胆管损伤25例(0.066%),其中术中发现8例,术后发现17例。胆管横断伤12例,其中离断+缺损8例(1例是中转开腹损伤),钛夹夹闭无胆管缺损4例;胆总管部分剪切伤4例;肝总管电损伤2例,分离损伤2例;右肝管损伤3例;副肝管损伤2例。胆管修补(端端吻合)+T管支撑引流5例、胆肠Roux-en-Y吻合16例,腹腔穿刺+鼻胆管引流1例(ENBD)、损伤胆管修复,置管引流3例。无死亡病例。结论:熟悉肝门解剖,仔细处理Calot三角,适时中转开腹,避免盲目自信可以有效的降低胆管损伤的发生率。     

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??Main points of the iatrogenic bile duct injury repair and repair of restenosis after treatment LIANG Li-jian.Department of Hepatobiliarypancreatic Surgery??the First Affiliated Hospital of Sun Yat-sen University??Guangzhou 510080??China
Abstract Bile duct injury ??BDI?? becomes a serious iatrogenic complication of hepatobiliary surgery. The incidence of BDI presents an ascending trend resulting from the rapid development of laparoscopic cholecystectomy. Surgery remains the primary treatment of BDI and a successful repair of BDI should be performed by an experienced senior hepatobiliary surgeon. As recurrence of biliary stricture are common after repair of BDI??a close follow-up and multidisciplinary treatment team consist of hepatobiliary surgeon??gastrointestinal surgeon??endoscopists and interventional radiologist is recommended to make a comprehensively cooperative diagnostic and therapeutic plan. Either hepatectomy or liver transplantation can achieve a satisfactory long-term outcome in certain subsets of BDI patients.