腹腔镜联合胆道镜胆总管探查382例

目的 :探讨运用腹腔镜联合胆道镜术中诊断治疗肝外胆管疾病。方法 :根据病史及术前B超检查结果 ,对可疑胆道疾病患者在LC术中行胆道镜检查 ,明确胆道情况。结果 :同期行LC手术 10 396例 ,术中胆道镜检查 382例 ,占 3 6 %,胆道系阳性发现 10 2例 ,占 2 7%,占同期LC手术的 0 9%。其中胆道结石6 7例 ,胆总管下端良性狭窄 2 6例 ,Mirrizzi综合征 5例 ,壶腹部癌 2例 ,肝门部胆管癌、胆道内蛔虫各 1例。结论 :LC术中联合胆道镜检查成功率高 ,显像清晰 ,可观察到术前常规检查不易发现的胆道内疾病 ,并可同时进行定位及定性诊断 ,提供合理的术式 ,有效地预防LC术后并发症的发生。     

腹腔镜联合内镜技术治疗胆囊结石合并胆管结石的临床研究

目的 探讨腹腔镜联合内镜技术在治疗胆囊结石合并胆管结石中的临床应用价值。方法 对2000-2005年应用腹腔镜联合十二指肠镜和纤雏胆道镜治疗的118例胆囊结石合并肝内外胆管结石病人行回顾性分析。其中胆囊结石合并胆总管结石102例，胆囊结石合并胆总管结石和左肝管结石16例。手术方式包括腹腔镜胆囊切除术（LC）联合经内镜括约肌切开术（EST）（49例）、LC联合胆道镜胆道棵查术（62例）、LC联合腹腔镜下左肝叶切除和胆道镜胆管棵壶术（7例）。结果96例病人术后得到随访和定期复查。影像学检查提示无残留结石。术后无严重并发症。4例接受LC结合胆道镜胆道棵查术的病人，中转开腹手术，其中2例由于存在离位胆管狭窄。1例由于肝门部严重粘连水肿，1例由于不易控制的动脉性出血。结论腹腔镜联合内镜治疗胆囊结石合并胆管结石安全、可行、疗效良好，应该在胆系结石病的治疗中得到推广应用。     

腹腔镜术中胆总管的探查

目的 探讨腹腔镜胆囊切除术中应用胆道镜探查的方法及价值。方法 腹腔镜胆囊切除术中对5例疑有胆系疾病的患行纤维胆道镜检查和治疗。结果 胆总管探查未见异常1例,胆管结石4例,其中3例在腹腔镜下经胆囊管取石成功,1例中转开腹。结论 LC术中应用纤维胆道镜可对胆总管进行探查和治疗。扩大了LC手术适应证范围。提高了一期手术的治愈率。     

胆道镜、钬激光在腹腔镜肝内外胆管结石治疗中的应用

目的:探讨胆道镜、钬激光联合腹腔镜治疗肝内外胆管结石的疗效及应用价值。方法:应用腹腔镜、胆道镜、钬激光治疗肝内外胆管结石128例,行胆总管切开取石,T管引流或一期缝合。结果:手术均获成功,无中转开腹。术后胆总管无残留结石。2例合并肝内胆管结石患者,10个月内胆总管结石复发。结论:胆道镜、钬激光联合腹腔镜治疗肝内外胆管结石安全、有效且微创。     

腹腔镜胆囊切除术联合ERCP解决术中棘手问题30例分析

目的:探讨腹腔镜胆囊切除术(LC)术中联合逆行胰胆管造影术(ERCP)处置解剖及胆管病变等较棘手问题的方法。方法:对30例LC术中较棘手的问题联合ERCP处理,包括继发性胆管结石、胆囊管畸形的辩认以及术中胆道损伤的判断和进一步处理。结果:30例均能通过ERCP对所遇到比较棘手问题予以解决,LC术中发现胆总管继发结石16例,均在ERCP下行EST取石术;LC术中发现Mirizzi综合征3例,均先放置鼻导管或支架在胆管内,然后行LC术;LC术中发现胆道损伤5例,其中右肝内胆管损伤1例,中转开腹手术,肝总管、胆总管损伤各2例,均行腹腔镜下胆道探查T管引流术;术中发现肝内外胆管畸形共6例,其中胆囊管开口于右肝管4例,双胆囊管畸形1例,均行LC术;右肝管开口于胆囊管1例,术中行ERCP时发现胆管损伤,遂中转开放手术。结论:LC术中遇到棘手的胆道问题时,联合ERCP治疗可减少术中、术后严重并发症的发生。     

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。     

应用腔镜技术治疗肝内外胆管结石的临床研究

目的探讨腔镜技术在治疗肝内外胆管结石中的合理应用. 方法应用腹腔镜结合十二指肠镜和纤维胆道镜治疗96例肝内外胆管结石,其中胆囊结石合并胆总管结石72例,单纯胆总管结石16例,左肝管结石合并胆总管结石8例.主要术式包括腹腔镜胆囊切除联合EST(37例)、腹腔镜胆囊切除术结合胆道镜胆道探查术(54例)、腹腔镜下左肝叶切除联合胆道镜胆管探查术(5例). 结果 96例中,93例术后复查无残留结石.4例出现少量胆漏,平均10天内自愈,无其它严重并发症发生.3例中转开腹手术,其中2例由于存在高位胆管狭窄,1例由于肝门部严重粘连水肿. 结论腔镜治疗肝内外胆管结石可行,合理应用多种腔镜技术治疗肝胆管结石,可以达到安全、有效和微创的目的.     

腹腔镜联合胆道镜治疗肝外胆管结石的方法探讨

目的:探讨腹腔镜联合胆道镜治疗肝外胆管结石的手术方法及临床经验.方法:回顾分析32例患者行腹腔镜联合胆道镜治疗肝外胆管结石的临床资料.结果:31例患者成功完成腹腔镜胆总管探查术,其中经胆囊管胆道镜取石5例,胆总管切开取石一期缝合16例,胆总管切开取石"T"管引流术10例;1例中转开腹.术后所有患者均治愈,4例并发胆漏,...     

腹腔镜联合胆道镜行胆道再手术治疗肝外胆管结石的临床疗效

目的探讨腹腔镜联合胆道镜行胆道再手术治疗肝外胆管结石的疗效。方法回顾性分析2009年9月至2011年12月第三军医大学西南医院收治的41例肝外胆管结石患者的临床资料,其中单纯胆总管多发结石30例,胆总管结石合并残余胆囊及胆囊管结石11例;1次手术史者23例,2～3次手术史者18例。采用腹腔镜联合胆道镜进行再次手术取石。采用电话方式进行随访,随访时间截至2012年6月。结果39例患者成功完成腹腔镜联合胆道镜行胆道再手术,手术成功率为95．1％（39／41）。2例患者因胆管狭窄及肝门部致密粘连中转开腹手术。术中出血量为（33±10）mL,手术时间为（150±39）min,术后胃肠功能平均恢复时间为2d,术后住院时间为（6．5±2．5）d。患者术后无严重并发症发生,全部痊愈出院。39例患者平均随访时间为7个月（2～27个月）,无结石残留及复发,无胆管狭窄。结论腹腔镜联合胆道镜行胆道再手术治疗肝外胆管结石安全有效,具有创伤小、恢复快及并发症少的优点。     

十二指肠镜、腹腔镜序贯治疗胆石症2 248例分析

目的探讨十二指肠镜、腹腔镜序贯性诊治胆石症的价值. 方法回顾性分析2000年1月～2004年12月采用十二指肠镜、腹腔镜序贯性诊治方案治疗胆石症2 248例的临床资料. 结果确诊胆囊结石1 817例,胆囊结石合并胆总管结石431例.B超诊断为胆囊结石2 021例中,行术前ERCP 690例,发现胆总管结石213例;术中胆道造影(IOC)85例,发现胆总管结石10例;腹腔镜胆囊切除(LC)术后胆总管残余结石6例,并经EST治愈.B超诊断胆囊结石合并胆总管结石227例中,ERCP证实胆总管结石202例.行LC 1 817例,EST LC 395例,LBDE 36例(其中胆管一期缝合26例,T管引流10例).全组中转开腹28例(1.2%),并发症52例(2.3%). 结论十二指肠镜、腹腔镜序贯性诊治方案治疗胆石症,体现了内镜、腔镜联合应用的优势,术后残余结石率低,微创治疗成功率高.     

腹腔镜胆囊切除术后胆总管残留结石的转归

目的:研究腹腔镜胆囊切除术(laparoscop ic cholecystectomy,LC)后胆总管残留结石的处理及转归。方法:回顾分析我院1992年4月至2006年6月15 000余例LC术后28例胆总管残留结石的原因、治疗及转归。结果:LC术后28例胆总管残留结石中结石自行排出3例,ERCP确诊25例,25例通过EST成功取石,其中1例为术后胆漏并发胆管结石。结论:通过加强术前检查、术中仔细操作和术后积极处理,可减少LC术后胆总管残留结石及其他严重并发症的发生。     

腹腔镜胆囊切除术后再疼痛的原因分析及预防

目的探讨腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）后再疼痛的原因及其预防措施。方法回顾性分析2000年1月～2006年1月168例LC术后再疼痛患者的临床资料（非切口创伤引起;LC术后并发症引起;LC术后1年内又出现类似术前症状;LC术前症状符合胆囊炎并胆囊结石症状,而未能进一步完善诊断,术后又出现LC术前相同症状及新发症状,考虑为其他病因引起的LC术前疼痛症状）。并对其术后再疼痛的原因及处理进行总结。结果颈肩痛24例;戳口痛5例;持续性腹腔内疼痛71例,其中28例胆漏,23例继发胆总管结石,6例术后急性胰腺炎,残株胆囊炎和（或）胆囊管残余结石8例,肝下间隙积液感染5例,十二指肠球部溃疡1例;阵发性腹部疼痛32例,其中9例为肠蠕动亢进,23例胆道运动障碍;黄疸并疼痛31例,其中右肝管狭窄肝内胆管局灶性扩张7例,胆管炎10例,肝外胆管残余结石11例,壶腹癌2例,胆总管下端癌1例;胆道蛔虫症2例;腹胀诱发疼痛2例;剧烈恶心、呕吐诱发疼痛1例。168例均症状缓解,其中再手术、ERCP＋EST治疗86例,非手术治疗82例。168例随访1～36个月,无其他并发症发生。结论LC术后疼痛的原因涉及到围手术期的每个环节;完善LC术前检查,重视术中术后的每个环节是减少LC术后疼痛的关键。     

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??Extrahepatic bile duct injury caused by cholecystectomy??a clinical analysis of 16 cases LI Yu-ji, TIAN Yu-lin, KONG Fan-min, et al. Department of Gastrointestinal Surgery, the First Hospital of China Medical University, Shenyang 110001,China
Corresponding author: DONG Ming, E-mail: mingdong@mail.cmu.edu.cn
Abstract Objective To explore the repair timing and method of extrahepatic bile duct injury caused by cholecystectomy. Methods Final diagnosis time, repair timing and method of 16 cases of extrahepatic bile duct injury caused by cholecystectomy admitted between January 1985 and December 2009 in the Department of General Surgery, the First Hospital of China Medical University were analyzed retrospectively. Results Four cases were found during operation. Ten cases were diagnosed during early postoperation. Two cases were diagnosed during late postoperation. Jejunum Roux-en-Y anastomosis was performed in 12 cases of bile duct transection injury diagnosed during and after operation and 2 cases of bile duct stricture caused by laparoscopic cholecystectomy (LC). The therapeutic effect of 2 cases is difficult to assess because postoperative time was shorter than 6 months. Twelve cases had no cholangitis and other biliary tract infection. One case in the 5th day after LC had jaundice, in whom two titanium clip occlusion of the common bile duct were found during the second operation, and then removing the line titanium clips and making T tube drainage of common bile duct were performed. One case had bile leakage after small-incision cholecystectomy (MC), in whom endoscopic biliary drainage (ENBD) was performed. The case recovered 4 weeks later. Conclusion The right treatment should be made according to the duct injury time and degree. If it is not suitable for end to end anastomosis and self biological valve repairing, the bile duct jejunum Roux-en-Y anastomosis is a common and effective method.     

腹腔镜胆囊切除术中解剖变异的诊断与处理(附21例报告)

目的：探讨腹腔镜胆囊切除术（laparoscopic cholecystectorny,LC）解剖变异的诊断及处理。方法：回顾1996年6月至2006年6月开展LC6523例的临床资料,其中21例发生解剖变异,分析其发生、处理情况及预后。结果：解剖变异的21例中副肝管6例,胆囊管变异8例,胆总管变异1例,胆囊动脉走行变异3例,胆囊动脉瘤1例,内脏反位2例。中转开腹6例。发生并发症3例,均为胆道损伤,经处理恢复良好,无远期并发症发生。结论：LC术解剖变异于术前难以诊断,重视解剖变异,经过细致的解剖,手术一般可以获得成功。术中胆道造影可以及时发现并减少胆道损伤。经验丰富的肝胆外科医师修复胆道损伤可以减少手术远期并发症和降低死亡率。     

Total Laparoscopic Roux-en-Y Cholangiojejunostomy for the Treatment of Biliary Disease

Background and Objectives:

Roux-en-Y cholangiojejunostomy (RCJS) has been widely used in biliary bypass surgeries, but in most reported literature, an assisted mini-incision was needed, and studies reporting total laparoscopic Roux-en-Y cholangiojejunostomy (TLRCJS) are rare. The goal of this study was to investigate how to treat hepatic portal bile duct diseases and perform jejunojejunostomy and cholangiojejunostomy totally laparoscopically. We evaluated the feasibility of TLRCJS in treating biliary tract diseases.

Methods:

TLRCJS were performed in 103 patients from January 2000 to August 2011. There were 28 cases of recurrent choledocholithiasis combined with stricture of the common bile duct (CBD) after several stone extractions, 3 patients with iatrogenic bile duct injury, 24 patients with choledochal cyst, 36 patients with hepatic portal cholangiocarcinoma, and 12 patients with cancer of the pancreatic head and periampullary cancer. All surgeries were performed through 5 trocars. First, laparoscopic surgery on the CBD was performed according to the original disease. The CBD was opened and stones were extracted in choledocholithiasis patients. In iatrogenic injury patients, strictured CBD was resected and repaired. Dilated CBD or choledochal cyst with tumor was transected. In patients with malignant jaundice, the CBD was opened longitudinally. At the same time, the bile duct was prepared for cholangiojejunostomy. Second, the positions of the laparoscope and surgeons were altered. The jejunal mesentery and jejunum were transected, and side-to-side jejunojejunostomy (JJS) was performed. The laparoscope and surgeon positions were exchanged again; the Roux-en-Y biliary limb was lifted close to the residual bile duct; and side-to-side or end-to-side choledochojejunostomy (CJS) was performed. Finally, an abdominal drainage tube was placed.

Results:

All the surgeries were performed successfully. The diameter of the residual bile duct ranged from 0.4 to 3.2 cm (average, 0.9 cm). Three patients had postoperative bile leakage and were treated from 1 week to approximately 1 month with abdominal drainage. Postoperative intraperitoneal hemorrhage and stress ulcer of the stomach occurred in 2 patients with biliary tract injury combined with obstructive jaundice. One with intraperitoneal hemorrhage was cured by another laparoscopic surgery. The other patient was cured after 2 days of abdominal drainage, antacids, and hemostatic drug therapy. The follow-up duration of 95 patients was 4 to 93 months (average, 48.3 months). The follow-up rate was 92.2% (95/103). Patients with cancer died of metastasis or cachexia during 14-month follow-up with no postoperative complication. Reflux cholangitis occurred in 3 patients 2, 3, and 5 years after the operation, respectively. No anastomotic stricture or other complication was found in other patients during the follow-up.

Conclusions:

TLRCJS is the best and first choice for patients with biliary tract diseases that need biliary-jejunal anastomosis. But it is essential that the surgeon has proficiency in laparoscopic surgeries.     

Biliary stricture due to neuroma after an innocent blunt abdominal trauma

A traumatic neuroma of the biliary tract is rarely associated with biliary obstruction. However, when it arises in the common bile duct (CBD) and is associated with obstructive jaundice, it is difficult to distinguish it from bile duct cancer. We describe a patient who developed obstructive jaundice and itching, due to CBD stricture, 8 years after innocent blunt abdominal trauma. The stricture was resected and hepatico-jejunal anastomosis was performed. Histological examination revealed a traumatic neuroma and a fibrous scar around the common bile duct. Symptoms disappeared following surgical removal of the lesion. Blunt abdominal injury may cause the late onset of a fibrous scar and traumatic neuroma in the common bile duct. To our knowledge, a traumatic neuroma of the biliary tract after blunt abdominal trauma has not been reported previously. We review the clinical picture of this relatively rare problem, along with its diagnosis, pathogenesis and treatment.     

开腹胆系术后腹腔镜胆系再手术

目的 :探讨开腹胆系手术后腹腔镜胆系再手术的疗效。方法 :2 7例开腹胆系术后胆系病变患者 ,应用腹腔镜在直视下建立气腹 ,分离钩、超声刀交替分离腹腔、肝下粘连 ,解剖残余胆囊、胆道 ,术中胆道造影 ,纠正解剖路线和术前诊断 ,在腹腔镜下行残留胆囊切除、胆道探查、取石、胆道Ⅰ期缝合、T管引流与胆肠吻合术。结果 :在腹腔镜下 2 7例的残留胆囊切除、胆道解剖、术中造影均获成功 ,排除胆道肿瘤 2例 ,完成LC7例 ,探查胆道、取石、胆道Ⅰ期缝合 4例 ,T管引流 13例 ,胆总管 十二指肠吻合 3例 ,其中老年胆总管囊肿 1例、老年胆道下段恶性肿瘤 2例 ,胆总管狭窄胆肠Roux en Y吻合术 1例 ,胆道肿瘤 2例存活 4 ～13个月 ,余者随访 1～37个月无近远期手术并发症发生。结论 :开腹胆系术后腹腔镜下胆系再手术安全有效 ,但对医师的手术技巧要求较高 ,应根据病情设计不同的手术方式。     

三孔法腹腔镜胆总管探查术21例分析

目的:探讨三孔法腹腔镜胆总管探查与"T"管引流术在临床上的应用价值。方法:采用三孔法行21例手术,于腹腔镜下切开胆总管,纤维胆道镜探查胆总管,取石网篮取石后,置"T"管引流。术后45d拔"T"管,经"T"管窦道纤维胆道镜探查肝内外胆道情况。结果:手术均获成功,无中转开腹,手术时间(70±24)min,术后无胆漏。术后45d经"T"管窦道纤维胆道镜探查,发现胆总管残余结石2例,肝内胆管结石3例,均经胆道镜取出。结论:三孔法腹腔镜胆总管探查术操作安全、可靠,具有一定的临床应用价值。     

腹腔镜超声辅助下复杂类型的腹腔镜胆囊切除术

目的：评估腹腔镜超声在复杂的腹腔镜胆囊切除（LC）术中避免胆道损伤及胆总管结石残留的作用。方法:104例LC因肝外胆系解剖变异,胆囊管真实性不确定,疑有胆总管结石或胆道损伤,三角区粘连或炎症,急性或萎缩性胆囊炎等被界定为复杂的LC患者,借助腹腔镜术中超声检查（LUS）显示的胆总管下端,肝外胆管与胆囊壶腹,胆囊管之间的解剖关系施行LC。结果：在LUS辅助下顺利完成复杂的LC85例,19例因LUS提示的潜在胆道损伤危险,胆总管下段结石,及疑有胆道损伤而中转开腹手术。结论：通过LUS显示的肝外胆管,并在术野中胆囊管,胆囊壶腹的参照下,可了解肝外胆系诸结构之间的解剖关系,由此避免胆道损伤,LUS还可发现隐匿的胆总管结石,LUS是复杂LC术中有效的辅助手段。