腹腔镜胆囊切除术中肝外胆管损伤的原因与预防

1991．9～1994.3月我院共做LC1750例，发生肝外胆管损伤4例，胆囊管残端瘘1例，迷走胆管损伤1例，外院转入LC术中胆管损伤2例，本文讨论LC术中肝外胆管损伤发生的原因及预防：(1)把胆总管误认为胆囊管将其钳闭切断，本组3例。     

腹腔镜胆囊切除术肝外胆管损伤的预防

目的探讨腹腔镜胆囊切除术肝外胆管损伤的预防。方法收集我院650例腹腔镜胆囊切除术的临床资料,总结预防手术肝外胆管损伤的方法。结果650例腹腔镜胆囊切除术有1例肝外胆管损伤,发生率0.17%。结论腹腔镜胆囊切除术通过严格选择手术适应证,注意胆道系统的解剖学变异,正确处理复杂病理改变,在困难的腹腔镜胆囊切除术中适时中转开腹,可以减少腹腔镜胆囊切除术的肝外胆管损伤。     

腹腔镜胆囊切除术肝外胆管损伤的防治

目的 研究腹腔镜胆囊切除术中预防肝外胆管损伤的有效措施。方法 分析我院近10年行腹腔镜胆囊切除术10800例，其中肝外胆管损伤8例，损伤率0.08%，以肝外胆管横断伤最多见6例，其余电灼伤和钳闭坏死各1例。8例损伤均发生在开展腹腔镜前5年的5000例中，后5年5800例LC未发生肝外胆管损伤。结果 8例肝外胆管损伤均行胆肠Roux-en-Y吻合治愈。结论 良好显露Calot三角，靠胆囊纯性分开Calot三角，认淮胆囊壶腹与胆囊管交汇部并游离出其延伸段是确认胆囊管的可行方法，此时，多能辨认清肝总管，胆总管，胆囊管，胆囊壶腹即“三管一壶腹”的相互解剖关系，可有效避免肝外胆管损伤。     

腹腔镜胆囊切除术中肝我胆管损伤及处理

自１９９２年１月－１９９６年１月，１２５０人因胆囊结石或胆囊息肉样病变在本院施行ＬＣ，胆管损伤７例，损伤类型包括：（１）这或直管横断各１例；９２）直管部分横断２例；（３）电凝损伤总肝管及右肝和各１例；（４）钛夹钳夹石肝眨１例。本组处理方法为胆管修补、胆管对端吻合及空肠Ｒｏｕｘ－Ｙ吻合术。本文认为术者损伤经验不足、不适当的止血操作、胆囊病因素及解剖不清是导致胆管损伤的原因。胆管损伤最重要的仍然是术中     

腹腔镜胆囊切除术中预防肝外胆管损伤的体会

为探讨腹腔镜胆囊切除术中如何避免肝外胆管损伤，总结我院1998年6月-2002年5月565例腹腔镜胆囊切除术的临床资料。全部病例无肝外胆管损伤，无中转开腹。我们认为，在紧贴胆囊颈部胆囊管分离时，Calot三角上壁之左角和左侧壁是非常重要的视点。只有显示出左上角是向上延续的胆囊颈，左壁是裸露的肝脏或肝表面之薄层结缔组织，此时右侧与胆囊颈相连的唯一管道为胆囊管才是无疑的。     

腹腔镜胆囊切除术预防肝外胆管损伤的体会

我院于１９９６年５月至２０００年５月共行腹腔镜胆囊切除术（Ｌａｐａｒｏｓｃｏｐｉｃ　Ｃｈｏｌｅｃｙｓｔｃｔｏｍｙ　ＬＣ）３２４例，现就肝外胆管损伤的预防措施讨论如下。 临床资料与方法 一、一般资料 本组３２４例，其中男１２９例，女１９５例。年龄２４～７９岁，平均４８岁。慢性胆囊炎。胆囊结石２８９例，急性胆囊炎、胆囊结石２１例，胆囊息肉样病变１４例。 二、手术要点 常规腹壁戳４孔，造气腹及置入相应器械操作［１］。术者左手持钳钳夹胆囊颈上部，将胆囊颈向右侧牵引使胆囊管紧张，在胆囊颈管交界处用电凝钩切开此…     

腹腔镜胆囊切除术肝外胆管损伤24例分析

目的总结腹腔镜胆囊切除术(LC)并发肝外胆管损伤患者的临床资料,分析LC并发肝外胆管损伤的原因、诊断、处理方法,探讨LC并发肝外胆管损伤的预防措施。方法回顾性分析1994年6月至2013年12月6130例LC术肝外胆管损伤24例患者的临床资料。结果共24例肝外胆管损伤的患者,发病率为0.39%,其中,胆总管不完全性横断伤1例,胆总管完全性横断伤11例(其中3例伴组织缺损),胆总管钛夹夹闭伤1例,胆总管机械性裂伤5例,胆总管电灼伤3例,肝总管部分缺损1例,右副肝管横断伤2例。均于LC术中或术后及时确诊,经处理后获得治愈,无死亡病例,随访3~10年,无任何后遗症发生。结论腹腔镜胆囊切除术(LC)肝外胆管损伤发病率仍较高,值得重视,肝外胆管损伤是可以通过努力而预防的。一旦明确胆管损伤应及时正确的处理,争取一次修复成功,可以避免造成胆道再狭窄等后遗症发生。     

腹腔镜胆囊切除术并发肝外胆管损伤的诊治

肝外胆管损伤是腹腔镜胆囊切除术（laparoscopic cholecystectomy，LC）较严重的并发症之一，我院1996年12月～2005年5月共实施1621例LC，并发肝外胆管损伤13例，现就外科诊治体会报道如下。     

腹腔镜胆囊切除术中肝外胆管损伤的预防措施

分析10年间行腹腔镜胆囊切除术（LC）715例，其中顺行LC 585例，逆行LC 125例，中转开腹胆囊切除术（OC）5例。LC成功率99.3%（710/715）。无肝外胆管损伤。笔者的经验是，不盲目追求“三管一壶”的完全显露，顺行LC，逆行LC和适时中转OC的结合应用，避免不正确操作以及注意胆囊管的局部解剖变异，是避免LC中肝外胆管损伤的有效措施     

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.     

腹腔镜胆囊切除术后胆管损伤围手术期处理

目的探讨腹腔镜胆囊切除术后胆管损伤围手术期的处理方法。方法分析我院1989年1月至2005年6月收治的38例腹腔镜胆囊切除术后胆管损伤的临床资料,结合随访结果总结有关围手术期处理方面的经验。结果38例胆道重建包括胆肠吻合术29例和对端吻合及胆管修补术9例,术后均放置胆道支撑管;术后发生胆瘘5例（13．15％）,切口感染4例（10．52％）,腹腔积液3例（7．89％）。胆道引流管3～4周内拔除31例;5～6周拔除7例。随诊6个月～15年,平均93个月,33例（86．84％）手术效果良好,5例（13．16％）术后吻合口狭窄,其中3例再次手术治愈,2例经十二指肠镜介入球囊扩张好转。结论胆管损伤宜术中及时发现和合理的处理;胆管损伤导致严重腹腔感染应尽早探查引流择期再行胆道重建术;胆道重建术后吻合口再狭窄处理前须获得满意的影像学检查结果;是否胆管重建术后常规放置支撑管和通过介入方法行胆管扩张治疗胆道狭窄的疗效有待进一步研究。     

Bile duct injuries during laparoscopic cholecystectomy

Background: With the introduction of laparoscopic cholecystectomy, an increase in the incidence of bile duct injury two to three times that seen in open cholecystectomy was witnessed. Although some of these injuries were blamed on the ``learning curve,' many occurred long after the surgeon had passed his initial experience. We are still seeing these injuries today. Methods: To better understand the mechanism behind these injuries, in the hope of reducing the injury rate, 177 cases of bile duct injury during laparoscopic cholecystectomy were reviewed. All records were studied, including the initial operative reports and all subsequent treatments. Videotapes of the procedures were available for review in 45 (25%) of the cases. All X-ray studies, including interoperative cholangiograms and ERCPs, were reviewed. Results: The vast majority of the injuries seen in this review (71%) were a direct result of the surgeon misidentifying the anatomy. This misidentification led to ligation and division of the common bile duct in 116 (65%) of the cases. Cholangiograms were performed in only 18% (32 patients) of cases, and in only two patients was the bile duct injury recognized as a result of the cholangiogram. Review of the X-rays showed that in each instance of common bile duct ligation and transection in which a cholangiogram was performed the impending injury was in evidence on the X-ray films but ignored by the surgeon. Conclusions: From this review, several conclusions can be drawn. First and foremost, the majority of bile duct injuries seen with laparoscopic cholecystectomy can either be prevented or minimized if the surgeon adheres to a simple and basic rule of biliary surgery; NO structure is ligated or divided until it is absolutely identified! Cholangiography will not prevent bile duct injury, but if performed properly, it will identify an impending injury before the level of injury is extended. And lastly, the incidence of bile duct injury is not related to the laparoscopic technique but to a failure of the surgeon to translate his knowledge and skills from his open experience to the laparoscopic technique. Received: 14 May 1996/Accepted: 1 July 1996     

腹腔镜胆囊切除术胆管损伤46例报告

目的探讨腹腔镜胆囊切除术（laparoscopic cholecystectomy，LC）中减少或避免胆管损伤的术中判断和操作技巧。方法回顾分析我院1992年10月～2005年10月39860例LC的临床资料，其中胆管损伤46例。结果行胆管裂口修补，置T管支撑引流26例；游离两断端，做端端吻合，T管支撑引流4例。T管支撑时间3～12个月。胆管空肠的Rouxen-Y吻合11例；副肝管结扎5例。胆管狭窄再手术4例，胆肠吻合口狭窄再手术2例。结论深刻的解剖认识，熟练的操作技巧可以避免或减少胆管损伤的发生。早期诊断和处理胆管损伤避免急性炎症期是防止多次胆道手术的重要举措。     

腹腔镜胆囊切除术预防胆道损伤的体会

目的　探讨腹腔镜胆囊切除术胆道损伤的防治方法。方法　回顾性总结 32 0例腹腔镜胆囊切除术的经验。结合文献复习分析胆道损伤可能发生的原因以及其预防和处理。结果　 32 0例腹腔镜胆囊切除术无 1例胆道损伤。结论　腹腔镜胆囊切除术胆道损伤的预防是关键。损伤的处理应根据发生的时间、部位及程度等选择不同的方法     

胆囊切除术胆管损伤的原因分析与处理

目的探讨胆囊切除术导致胆管损伤的原因及损伤后的处理方式。方法对21例胆囊切除术引起胆管损伤的损伤原因及处理方式的临床资料进行回顾性分析。结果损伤原因主要有：（1）胆囊急性炎症期进行手术8例,（2）经验不足5例,（3）Calot三角结构不清3例和解剖变异3例,（4）术中出血导致损伤2例。在处理方式上,本组有3例在术中发现胆管损伤后即时进行修复,12例在术后14d内修复,均取得良好的效果。另外6例在损伤后15d-95d之间进行修复,其中4例恢复良好,1例术后存在慢性胆管炎,死亡1例。绝大部分17例的病例采用胆管空肠Roux-en-Y吻合术,恢复良好15例。结论胆囊切除术导致的胆管损伤应由有经验的肝胆外科专科医生进行修复．早期修复是可行的,胆管空肠吻合术是首选的手术方式。     

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.     

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.     

腹腔镜胆囊切除术预防肝外胆管损伤的探讨

目的 :研究腹腔镜胆囊切除术中预防肝外胆管损伤的有效方法。方法 :分析腹腔镜胆囊切除术10 80 0例的临床资料 ,肝外胆管损伤 8例 ,损伤率 0 0 8% ,以肝外胆管横断伤多见共 6例 ,电灼伤和钳闭坏死各 1例。 8例损伤均发生在开展腹腔镜前 5年的 5 0 0 0例中 ,后 5年 5 80 0例LC无发生肝外胆管损伤患者。结果 :8例肝外胆管损伤均行胆肠Roux -en -y吻合术治愈。结论 :良好显露Calot三角 ,靠胆囊钝性分开Calot三角 ,认准胆囊壶腹与胆囊管交汇部并游离出其延伸段是确认胆囊管的可行方法 ,此时 ,多能辨清肝总管、胆总管、胆囊管、胆囊壶腹即“三管一壶腹”的相互解剖关系 ,可避免损伤肝外胆管