腹腔镜胆囊切除术中胆管损伤的调查分析

目的 调查分析腹腔镜胆囊切除术(LC)中引起胆管损伤的原因和损伤后的处理方法.方法 对广东省内10家大型三甲医院所发生的和收治外院转入的LC胆管损伤病例进行调查,获得自1993年10月至2007年11月发生的LC胆管损伤病例110例,对病例数据进行统计学分析.结果 110例LC胆管损伤病例中,在该10家大型医院内发生者58例(52.7%),而在外院损伤后转入者52例(47.3%).损伤原因包括:(1)经验不足(48.2%);(2)胆囊急性炎症期进行手术(20.0%);(3)Calot 三角结构不清(15.5%)和解剖变异(11.8%);(4)术中出血导致损伤(4.5%).损伤部位主要在胆总管和肝总管.106例接受且H管修复手术或内镜下放置胆管支架,术后恢复良好率达95.3%,病死率为0.9%,有3.8%的病例手术后仍有胆管炎发作.有63例患者采用胆管空肠吻合手术治疗,术后恢复良好率达93.7%;修复手术在损伤后30 d内实施的占63.2%;83.0%的病例一次手术修复成功.结论 经验不足和解剖不清等主观因素是LC术中胆管损伤的主要原因;LC术中胆管损伤的修复需要由有胆管修复经验的肝胆外科医牛进行,及时转诊可以使患者获得良好的疗效.早期进行修复是可行的.

A survey of bile duct injuries sustained during laparoscopic cholecystectomy

Objective To summarize the reasons for bile duct injury (BDI) after laparoscopic cholecysteetomy (LC), and to determine the effect of multiple treatment after BDI.Methods A retrospective cohort study was performed.The medical records of 110 patients diagnosed with BDI after LC from October 1993 to November 2007 ,in ten large hospitals in Guangdong of China,were reviewed.Results Among 110 patients with BDI,58 cases (52.7% ) were local patients, whereas 52 cases (47.3%) were transferred from outside hospitals. Reasons for BDI following LC were: ( 1 ) I,ack of experience of the LC operator (48.2% );( 2 ) LC performed during acute cholecystitis ( 20.0% );( 3 ) The structure of Calot triangle was unclear ( 15.5% );(4) Variable anatomical position ( 11.8% );(5) Intra-operatian bleeding (4.5% ).The commonest sites of injury were the choledochas and common hepatic duet (76.4% ).Following BDl,endoscopic stenting or operative repair was performed in 106 patients.The overall success rate was 95.3% ( 101/106 ), with a mortality rate was O.9% ( 1/106 ).Cholangitis occurred in 3.8% (4/106 ) eases.Choledochoenterostomy operation was performed in almost 60.0% ( 63/106 ) cases, and the success rate was 93.7% (59/63). Endoscopic stenting or operative repair was performed immediately following BDI in 23.6% (25/106) patients, the success rate was 100%;and within 30 days in 63.2% (67/106) patients.Eighty-eight out of 106 patients who underwent repair were successful following the first operative procedure. Conclusions Factors such as an un-experienced operator and unclear anatomical position were causes of BDI following LC.Early operative repair should be regarded as the treatment of choice,in patients diagnosed with BDI. Early refer to an experienced hepatobiliary operator ensures a high success rate.