三结构确认胆囊管在预防腹腔镜胆囊切除术胆管损伤中的价值

目的 探讨腹腔镜胆囊切除术(LC)中避免医源性肝外胆管损伤的解剖学方法.方法 分析1992年3月至2006年5月间施行的LC 13 190例,其中在1992年3月至1996年5月间施行LC2698例,主要采用辨认胆囊管、胆总管和肝总管的三管法(即三管组);1996年5月至2006年5月间共施行10 492例,其中采用三管法8566例,另外1926例因胆管显露不太容易而采用在胆囊管位置解剖出的管状结构,结合分离Calot三角区中的胆囊淋巴结、胆囊壶腹、胆囊动脉以及胆囊三角区空虚这4项指标中的至少2项,帮助确认胆囊管的三结构确认胆囊管法(即三管+三结构组),分别就两组间的手术时间、中转开腹率、术中出血量及并发症等进行研究.结果 13 190例患者中无一例发生术中误伤胆管致黄疸、胆瘘等.三管组手术时间15～92 min,平均(38±16)min,中转开腹率为8.7%;三管+三结构组手术时间15～52 min,平均(28±12)min,中转开腹率为1.8%.两组手术时间差异有统计学意义(P<0.05),两组中转开腹率差异有统计学意义(P<0.05).而两组术中出血率和并发症率差异无统计学意义(P>0.05).结论 三结构确认胆囊管法不仅可以有效帮助确认胆囊管,避免医源性胆管损伤的发生率,而且可以缩短LC手术时间,降低中转率.

Value of identification of cystic duct,common bile duct,and common hepatic duct in prevention ofbile duct injury during laparoscopic cholecystectomy

Objective To explore effective method to avoid iatrogenic bile duct injury during laparoscopic cholecystectomy (LC). Methods 10 492 patients underwent LC from May 1996 to May 2006,8566 of them were treated by the method to identify the cystic duct,common hepatic duct,and common bile duct during LC (tri-duct method group),and the left 1926 cases whose cystic duct failed to be exposed easily were treated with the method to identify at least two of the 4 structures (cystic lymph node,Hartmann's pouch,cystic artery,and emptiness of cystic triangle) so as to help identify the cystic duct (tri-duct plus tri-structure group). The operating time,amount of blood loss,open conversion rate,and morbidity were compared between these 2 groups. Results No cases of bile leakage or jaundice because of accidental injury of bile duct were found. The operating time of the tri-duct plus tri-structure group was (28 ± 12) (15±52) min,significantly shorter than that of the tri-duct group (38 ± 16) ( 15-92) min,P < 0.05 ]. The open conversion rate of the tri-duct plus tri-structure group was 1.8%,significantly lower than that of the tri-duct group ( 8.7%,P < 0. 05 ). There were no significant difference in the amount of blood loss and morbidity between the two groups (both P > 0.05). Conclusion The tri-structure method can not only confirm the cystic duct correctly,thus preventing iatrogenic bile duct injury,but also shorten the operating time and reduce the open conversion ratio during LC.