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4例

胆管损伤是腹腔镜胆囊切除术（ laparoscopic cholecystecomy ,LC）的严重并发症之一,如不及时正确处理,往往会造成严重的不良后果。笔者自2008-01～2012-12共行LC 1033例,发生胆管损伤4例（0.39％）。现对4例 LC 胆管损伤的原因进行分析,并就其处理方法与预防措施讨论如下。     

腹腔镜下胆囊切除术1650例无胆管损伤的体会

目的 探讨如何预防腹腔镜胆囊切除术中胆管损伤。方法 回顾1995-10／2004-12间1650例腹腔镜胆囊切除手术病例的临床资料进行分析。结果 17例因胆囊Calot三角严重黏连、胆囊萎缩而中转开腹。1650例无一例胆管损伤并发症。术后2-6d出院，平均4d。结论 开展腹腔镜胆囊切除术应适当选择病例，仔细处理Calot三角，适时中转开腹是预防胆管损伤的重要措施。     

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。     

腹腔镜胆囊切除术胆管损伤的诊断及处理

目的总结腹腔镜胆囊切除术（LC）胆管损伤的特点及诊断和处理的经验教训。方法回顾性分析23例LC胆管损伤的诊治情况。结果主胆管损伤12例，其中胆总管横断6例，肝总管横断2例，右肝管横断1例，胆总管横行夹闭1例，胆总管和肝总管裂孔各1例。副肝管损伤11例，其中迷走胆管损伤1例，细小副肝管损伤7例，较粗大的副肝管损伤3例。本组病例全部治愈。结论LC较开腹胆囊切除术更易发生胆管损伤，且损伤更为隐蔽、复杂，处理难，预后差。应根据不同的情况选择适当的手术方式．     

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…     

腹腔镜胆囊切除术导致胆管损伤的外科治疗

目的 探讨腹腔镜胆囊切除术(LC)所致胆管损伤的外科治疗方法及疗效.方法 回顾性分析1992年1月～2005年12月间我院收治的LC导致胆管损伤的37例病人的临床资料,并结合随访结果进行分析总结.结果 37例病人中15例胆管损伤在我院发生,22例为外院发生.胆管修补(或端端吻合)+T管支撑引流术5例(13.5%),胆管空肠Roux-en-Y吻合术29例(78.4%),经B超引导腹腔穿刺置管引流1例(2.7%),长期保留LC术中所置腹腔引流管2例(5.4%).术后无死亡病例,10例(27%)病人出现至少一个手术后并发症,其中包括切口感染5例(16.2%),吻合口狭窄3例(8.1%),腹腔脓肿5例(16.2%),手术后均经气囊扩张或经皮穿刺置管引流后好转,没有病人需要冉次手术治疗,远期随访有效率为100%.结论 胆管损伤是腹腔镜胆囊切除术中常见的严重并发症,采用恰当的外科治疗方法町获得较好的疗效.     

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。     

单中心腹腔镜胆囊切除致胆管损伤近年变化及特点分析

目的总结单中心腹腔镜胆囊切除致胆管损伤近年的变化及特点。方法回顾性分析总结近期组（2003年6月至2009年3月）和早期组（1992年10月至1998年6月）进行腹腔镜胆囊切除术（LC）患者的临床资料,并进行对比分析。结果近期组18613例中发生胆管损伤11例（发生率0．06％）,包括胆管横断伤2例（1例是中转开腹以后发生）、胆管分离性损伤3例、电凝伤2例（肝总管1例、副肝管1例）、胆总管部分剪切伤2例、副肝管横断伤1例、中转开腹肝总管部分缝扎伤1例;早期组11796例中发生胆管损伤15例（发生率0．13％）,包括横断伤6例、电灼胆管侧壁伤6例、分离伤3例。近期组LC致胆管损伤的发生率明显低于早期组（χ2=3．92,P=0．04784）。结论近期组Lc致胆管损伤的发生率较早期组明显降低,损伤程度也在降低,但损伤种类在不断增加,依据胆管损伤的类型进行“个体化”处理可减少胆管进一步损伤以及术后并发症的发生。     

腹腔镜胆囊切除术后再次手术18例临床分析

目的 探讨腹腔镜胆囊切除术（LC）后再次手术的原因。手术方式及其预防措施。方法 对18例LC后再手术患者的诊治进行回顾性分析。结果 再手术率0.84%，再手术的原因为胆道损伤3例。胆漏5例，胆总管残留结石6例，腹壁戳孔癌种植转移2例，胆囊管残端炎2例。17例经再手术治愈。1例因胆囊癌广泛转移死亡。结论 降低LC后再手术率的关键在于掌握好LC的适应证，术中正确的手术操作以减少并发症的发生，及对并发症的正确处理。     

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.     

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.     

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.     

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.     

Isolated right posterior bile duct injury following cholecystectomy:Report of two cases

Anatomic variations of the right biliary system are one of the most common risk factors for sectoral bile duct injury(BDI)during cholecystectomy.Isolated right posterior BDI may in particular be a challenge for both diagnosis and management.Herein we describe two cases of isolated right posterior sectoral BDI that took place during laparoscopic cholecystectomy.Despite effective external biliary drainage from the liver hilum in both cases,there was a persistent biliary leak observed which was not visible on endoscopic retrogradecholangiogram.Careful evaluation of images from both endoscopic and magnetic resonance cholangiograms revealed the diagnosis of an isolated right posterior sectoral BDI.These were treated with a delayed bisegmental(segments 6 and 7)liver resection and a Roux-en-Y hepaticojejunostomy respectively with good outcomes at 24 and 4 mo of follow-up.This paper discusses strategies for prevention of such injuries along with the diagnostic and therapeutic challenges it offers.     

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 ...