腹腔镜胆囊切除术胆管损伤的防治

腹腔镜胆囊切除术（ＬＣ）胆管损伤是严重并发症之一,甚至危及生命。为了减少胆管损伤的发生率,近年来我院采取综合性措施以避免这一并发症的发生,现报告如下。临床资料自１９９３年９月至１９９６年１２月,我院共完成１０５０例ＬＣ,男性２５６例,女性７９４例;年龄１７～８１岁,平均４３．５岁。本组胆囊结石９２７例,胆囊息肉１２３例。其中胆囊颈嵌顿结石１０２例,胆囊管嵌顿结石１８例,急性胆囊炎９２例,慢性萎缩性胆囊炎１０２例。伴有高血压１３９例、冠心病１２６例、糖尿病７８例、肝硬化５例、红斑狼疮２例,甲亢、甲…     

腹腔镜胆囊切除术胆管损伤的预防对策

腹腔镜胆囊切除术(LC)为手术治疗胆囊疾病的首选有效方法，但其发生胆管损伤的危险性明显大于开腹胆囊切除术。为预防LC术中胆管损伤，我们回顾性分析2001年10月至2004年10月连续实施LC500例无胆管损伤者临床资料。现报告如下。     

腹腔镜胆囊切除术预防肝外胆管横断性损伤

腹腔镜胆囊切除术预防肝外胆管横断性损伤周正东陈训如罗丁李胜宏余少明毛静熙段作纬刘成Ｓｕｂｊｅｃｔｈｅａｄｉｎｇｓｃｈｏｌｅｃｙｓｔｅｃｔｏｍｙ，ｌａｐａｒｏｓｃｏｐｉｃ／ａｄｖｅｒｓｅｅｆｅｃｔｓ；ｂｉｌｅｄｕｃｔｓ，ｅｘｔｒａｈｅｐａｔｉｃ／ｉｎ...     

腹腔镜胆囊切除术中预防胆管损伤的体会

国内开展腹腔镜胆囊切除术（LC）已近20a,但术中仍时有胆管损伤发生。2003年3月以来,我院对247例胆囊疾病患者施行LC术治疗。现报告如下。     

腹腔镜胆囊切除术预防肝外胆管损伤的体会

腹腔镜胆囊切除术(ＬＣ)中,肝外胆管损伤是一严重的并发症,我院自1992年1月至1999年6月施行ＬＣ18600例,发生肝外胆管损伤12例,报告如下。临床资料一、一般资料:本组12例中男性5例,女性7例。年龄34～66岁,中位年龄43岁。全麻、气腹下施行ＬＣ,手术时间9～56ｍｉｎ,平均(30±5)ｍｉｎ。病理诊断:结石性胆囊炎10例(其中急性胆囊炎4例,萎缩性胆囊炎3例),胆囊结石伴胆总管囊肿1例,胆囊腺瘤1例。二、肝外胆管损伤部位及诊断时间:胆总管损伤5例(4例横断伤,1例电切撕裂伤);右肝管横断伤3例;肝管、胆总管离断缺损伤3例;肝总管横断伤1例。本组病例于…     

腹腔镜胆囊切除术中防止胆管损伤的体会

腹腔镜胆囊切除术(LC)具有创伤小、痛苦少、进食早、恢复快等优点,已逐渐在临床上普及,但有时会损伤胆管。我们从2000年1月开始,采用顺逆结合、安全辨认结构法施行腹腔镜胆囊切除,至今已进行254例,取得良好的效果,报告如下。     

腹腔镜胆囊切除术中肝外胆管损伤的原因与预防

回顾性分析6 526例行腹腔镜胆囊切除术（LC）患者的临床资料。结果显示,患者术后发生胆管损伤5例,均经手术治疗治愈。认为LC术中暴露充分、钝性分离、准确识别胆囊壶腹和胆囊管交界部、避免电灼伤周围组织、冷静处理术中出血是减少或避免胆管损伤的重要措施。     

腹腔镜胆囊切除术胆管损伤4例报告

胆管损伤是腹腔镜胆囊切除术(ＬＣ)最严重的并发症之一[1],自1993年9月至1998年9月中间,我院共完成ＬＣ1866例,其中发生胆管损伤4例,现报告如下。腹腔引流管引出胆汁样液体,次日晨发现巩膜黄染,生化检查示梗阻性黄疸。急诊剖腹探查发现由于在胆囊管根部上夹入院。本组2例肝外胆管横断伤采用肝门胆管空肠ＲｏｕｘｅｎＹ吻合、Ｔ管支撑引流,效果良好。如果ＲｏｕｘｅｎＹ胆肠吻合术后发生胆漏,那么可导致继发性胆管狭窄,一旦发生,再次手术相当困难。胆管损伤的处理必须采取积极、慎重的态度,如果延误诊治,必然对机体产生严重损害,从而对胆管损…     

腹腔镜胆囊切除术中肝外胆管损伤的预防与处理

回顾性分析5例腹腔镜胆囊切除术中发生胆管损伤患者的临床资料。认为腹腔镜胆囊切除术中胆管损伤是其严重的并发症，须引起手术医生的高度重视；本病重在预防，一旦发生要及时处理。     

胆囊切除术胆管损伤的原因及预防方法

１材料和方法１９９０／１９９８共行胆囊切除术１６２０例,男３８６例,女１２３４例,年龄１６岁～８０岁其中胆囊结石１１３２例,胆囊息肉４５２例,非结石性胆囊炎３４例,其他２例合并心脏病１１２例,高血压６０例;Ⅱ型糖尿病２２例．１５３０例在持续硬膜外麻醉下手术,９０例在气管插管、全麻下手术根据手术方式的不同,将１６２０例患者分成２组：Ａ组,共８１２例,行常规胆囊切除术,即进入腹腔后直接游离胆囊管和胆囊动脉,并将其切断,然后再切除胆囊．Ｂ组,共８０８例,行胆囊管悬吊术,即进入腹腔后先解剖和游离胆囊管并…     

Delayed presentation of bile duct injuries after laparoscopic cholecystectomy

Bile duct injury is a serious complication of laparoscopic cholecystectomy, with 50% of bile duct injuries showing a delayed presentation. We experienced four patients (one male and three female) with bile duct injuries after laparoscopic cholecystectomy performed and referred by a local practitioner. The patients' ages ranged from 34 to 63 years. Symptoms included abdominal pain, anorexia, jaundice, ascites, ileus, fever, and tarry stool. Ductal injuries were a result of electrocautery burn in two patients and biliary strictures were due to malapplication of endoclips in the remaining two. The observed bile duct injuries, confirmed by ultrasonography, computed tomography (CT) scanning, and cholangiographic studies, were successfully treated by choledochotomy with a silastic T-tube stent. To avoid bile duct injuries, laparoscopic cholecystectomy should be performed by a well trained and experienced hepatobiliary surgeon, who should ensure accurate identification of the anatomical structures of Calot's triangle, careful dissection and management of intraoperative bleeding, and a lower threshold for conversion to open surgery.     

Analysis of bile duct injuries (Stewart-Way classification) during laparoscopic cholecystectomy

In order to investigate mechanisms underlying the occurrence of bile duct injuries (BDIs) during laparoscopic cholecystectomy (LC), we analyzed results for 34 patients (0.59%; 17 men, 17 women; average age, 57 years) with BDI out of 5750 LCs, based on questionnaire responses from surgical operators, records of direct interviews with these operators, operative reports, and videotapes of the operations. The indications for LC in the 34 patients were chronic cholecystitis in 32 patients and acute cholecystitis in 2. The BDIs in these patients were divided into four classes using the Stewart-Way classification: class I, incision (incomplete transection) of the common bile duct (CBD), n = 6 (17.6%); class II, lateral damage to the common hepatic duct (CHD), n = 9 (26.5%); class III, transection of the CBD or CHD, n = 15 (44.1%); and class IV, right hepatic duct or right segmental hepatic duct injuries, n = 4 (11.8%). In all class III and 3 class I cases (18 in total; incidence 53%), the mistake involved misidentifying the CBD as the cystic duct. Of all types (classes) of injuries, class III injuries showed the mildest gallbladder inflammation, and there was a significant (P = 0.0005) difference in the severity of inflammation between class II and III injuries. We conclude that complete transection of the CBD, which is rare in laparotomy, was the most common BDI pattern occurring during LC and that the underlying factor in the operator making this error was mistaking the CBD for the cystic duct.     

Mechanism,management, and prevention of bile duct injury in laparoscopic cholecystectomy

Injury to the bile duct is one of the most serious complications of laparoscopic cholecystectomy. The incidence of bile duct injury during laparoscopic cholecystectomy may be higher than during open cholecystectomy. Most of these injuries occur early in a surgeon’s experience with the new technique. The classical laparoscopic bile duct injury occurs when the common duct is mistaken for the cystic duct; the common bile duct is transected and a part of the extrahepatic biliary system is resected. The bile duct may also be injured by excessive diathermy, resulting in a bile leak or a stricture. Insecure clipping of the cystic duct may also result in bile leakage. If these injuries are not recognized at the time of surgery, they present as bile collections or jaundice postoperatively. ERCP will delineate the exact injury accurately. These injuries are preventable by careful attention to technique and a willingness to convert to open surgery when difficulties are encountered. To minimize the risk to patients, programs of training, proctoring, and accreditation in laparoscopic surgery should be established.     

Medicolegal costs of bile duct injuries incurred during laparoscopic cholecystectomy

Background:

When laparoscopic cholecystectomy (LC) is performed successfully, recovery is faster than after open cholecystectomy. However, LC results in higher incidences of biliary, bowel and vascular injury.

Methods:

We performed a retrospective review of LC-related claims reported to the National Health Service Litigation Authority (NHSLA) during 2000–2005. The data were analysed from a medicolegal perspective to assess the effects of type of injury and delay in recognition on litigation costs.

Results:

A total of 208 claims following laparoscopic procedures in general surgery were reported to NHSLA during 2000–2005, of which 133 (64%) were related to LC. Bile duct injury (BDI) accounted for the majority of claims (72%); bowel injury and ‘others’ accounted for 9% and 19%, respectively. Only 20% of BDIs were recognized during surgery; the majority were missed and diagnosed later. Claims related to LC resulted in payments totalling £6 m, of which £4.3 m was paid out for BDIs. The average cost was higher for patients who suffered a delay in diagnosis, as was the chance of a successful claim.

Conclusions:

Bile duct injury incurred during LC remains a serious hazard for patients. The resulting complications have led to litigation that has caused a huge financial drain on the health care system. Delayed recognition appears to correlate with more costly litigation.     

Managing bile duct injury during and after laparoscopic cholecystectomy

Laparoscopic cholecystectomy is now the treatment of choice for gallstones, but there has been concern that bile leakage after a laparoscopic cholecystectomy is more frequent than after an open cholecystectomy. We have experienced 16 patients with bile duct injury after a laparoscopic cholecystectomy. Five patients had a circumferential injurury to the major bile duct, and we employed a converted open technique for biliary reconstruction. The other 11 patients had partial injurury to the major bile duct, and we performed laparoscopic restoration; all 11 of these patients received endoscopic retrograde cholangiography (ERC) on the day after the operation and stenting for biliary decompression and drainage. No complications were identified and the duration of hospitalization in these patients was significantly shorter than in those who had the converted procedure. If intraoperative cholangiography is performed routinely, the presence and form of bile duct injury can be clearly identified, and the decision to restore the site of injury or to convert to the open technique for biliary reconstruction can be made immediately.     

Prevention of common bile duct injury during laparoscopic cholecystectomy

BACKGROUND:Since the widespread adoption of laparoscopic cholecystectomy(LC)in the late 1980s,a rise in common bile duct(CBD)injury has been reported.We analyzed the factors contributing to a record of zero CBD injuries in 10 000 consecutive LCs. METHODS:The retrospective investigation included 10 000 patients who underwent LC from July 1992 to June 2007. LC was performed by 4 teams of surgeons.The chief main surgeon of each team has had over 10 years of experience in hepatobiliary surgery.Calot's triangle ...     

Right hepatic lobectomy for bile duct injury associated with major vascular occlusion after laparoscopic cholecystectomy

A 57-year-old woman underwent laparoscopic cholecystectomy (LC) for cholelithiasis. Continuous bile leak was observed beginning on the first postoperative day. Postoperative endoscopic retrograde cholangiography revealed bile leak through the common hepatic duct, and severe stenosis of the hepatic confluence. A total of three percutaneous transhepatic biliary drainage (PTBD) catheters were inserted to treat obstructive jaundice and cholangitis. The patient was referred to our hospital for surgery 118 days after LC. Cholangiography through the PTBD catheters demonstrated a hilar biliary obstruction. Celiac arteriography revealed obstruction of the right hepatic artery, and transarterial portography showed occlusion of the right anterior portal branch. On the basis of the cholangiographic and angiographic findings, we performed a right hepatic lobectomy with hepaticojejunostomy to resolve the bile duct obstruction and address the problem of major vascular occlusion. The patient's postoperative recovery was uneventful and she remains well 25 months after hepatectomy. We discuss a treatment strategy for bile duct injury suspected after LC, involving early investigation of the biliary tree and prompt intervention.     

Hepatic resection for post-cholecystectomy bile duct injuries: a literature review

Objectives:

This study seeks to identify factors for hepatectomy in the management of post-cholecystectomy bile duct injury (BDI) and outcome via a systematic review of the literature.

Methods:

Relevant literature was found by searching the PubMed database and the bibliographies of extracted articles. To avoid bias selection, factors for hepatectomy were analysed in series reporting both patients undergoing hepatectomy and patients undergoing biliary repair without hepatectomy (bimodal treatment). Relevant variables were the presence or absence of additional hepatic artery and/or portal vein injury, the level of BDI, and a previous biliary repair.

Results:

Among 460 potentially relevant publications, only 31 met the eligibility criteria. A total of 99 hepatectomies were reported among 1756 (5.6%) patients referred for post-cholecystectomy BDI. In eight series reporting bimodal treatment, including 232 patients, logistic regression multivariate analysis showed that hepatic arterial and Strasberg E4 and E5 injuries were independent factors associated with hepatectomy. Patients with combined arterial and Strasberg E4 or E5 injury were 43.3 times more likely to undergo hepatectomy (95% confidence interval 8.0–234.2) than patients without complex injury. Despite high postoperative morbidity, mortality rates were comparable with those of hepaticojejunostomy, except in urgent hepatectomies (within 2 weeks; four of nine patients died). Longterm outcome was satisfactory in 12 of 18 patients in the largest series.

Conclusions:

Hepatectomies were performed mainly in patients showing complex concurrent Strasberg E4 or E5 and hepatic arterial injury and provided satisfactory longterm outcomes despite high postoperative morbidity.