开腹胆囊切除术中右肝管变异与医源性胆管损伤的预防

目的探讨开腹胆囊切除术中遇到右肝管变异时，医源性胆管损伤的预防措施。方法回顾性总结了2001-2003年施行的928例胆囊切除术中遇到的右盯管变异16例，进行正确的外科处理。结果16个病例经手术治疗后无一例发生了医源性胆管损伤。结论思想上高度认识右肝管变异，采取正确的处理方法，医源性胆管损伤是能够预防的。     

肝管变异在腹腔镜胆囊切除术中引起胆管损伤的预防

探讨预防肝管变异患者腹腔镜胆囊切除术时出现医源性胆管损伤的方法。回顾性分析1993年4月—2013年12月开展腹腔镜胆囊切除术病例20 000例中出现的肝管变异及胆管损伤的情况;同时回顾性分析1993~2013年诊治的胆管损伤患者295例的具体诊治情况。在20 000例腹腔镜胆囊切除术病例中,发现肝管变异302例,变异率为1.51%。其中,副肝管280例,变异率1.40%;右肝管经胆囊三角汇入胆囊管8例;右肝管直接汇入胆囊壶腹9例;无右肝管主干,右前右后肝管直接汇入肝总管5例。发生轻度胆管损伤53例,无严重胆管损伤病例。在295例胆管损伤病例回顾性研究中,53例为上述开展20 000例腹腔镜胆囊切除术时发生的轻度胆管损伤患者;另外242例为其他医院LC胆管损伤后转入病例。根据Strasberg分类法对胆管损伤情况分型并治疗,本组15例行保守治疗,142例接受手术治疗,75例行纤维十二指肠镜治疗,35例行腹腔镜治疗,27例行腹腔镜联合纤维十二指肠镜治疗,1例发生急性梗阻性胆管炎死亡。副肝管变异在肝管变异中出现的概率最高,是引起胆管损伤的重要解剖因素。在术中解剖游离胆囊壶腹后间隙(胆囊后三角)时,证实没有异常管道后才离断胆囊管和胆囊动脉,这样便能有效的预防副肝管引起的胆管损伤。对于已经引起胆管损伤的患者应根据不同的情况采取对应的处理方式。     

开腹胆囊切除术中右肝管变异与医源性胆管损伤的预防

目的　探讨开腹胆囊切除术中遇到右肝管变异时 ,医源性胆管损伤的预防措施。方法回顾性总结了 2 0 0 1～ 2 0 0 3年施行的 92 8例胆囊切除术中遇到的右肝管变异 16例 ,进行正确的外科处理。结果　 16个病例经手术治疗后无一例发生了医源性胆管损伤。结论　思想上高度认识右肝管变异 ,采取正确的处理方法 ,医源性胆管损伤是能够预防的。     

腹腔镜胆囊切除术中右副肝管及右肝管损伤的预防及处理

目的 总结腹腔镜胆囊切除术中防治右副肝管及右肝管损伤的经验. 方法回顾性分析21例腹腔镜胆囊切除术右副肝管或左右肝管低位汇合、胆囊管汇入右肝管病例资料.结果 通过术中解剖肝门及胆道造影相结合的方法,21例病例中发现右副肝管18例(I-V型),左右肝管低位汇合、胆囊管汇入右肝管3例(Ⅵ型).其中,18例具有右副肝管病例中,术中发现11例,保留副肝管未做处理3例;夹闭7例,术后皆无胆漏;术中缝合1例,术后出现胆漏,保守治疗成功.损伤右副肝管7例,2例术中夹闭损伤肝管;2例中转开腹端端吻合损伤肝管;3例术后出现胆漏,二次腹腔镜探查证实右副肝管夹闭损伤.3例左右肝管低位汇合、胆囊管汇入右肝管病例,其中术中发现2例;损伤1例,中转开腹行右肝管端端吻合.21例随访2年,皆无腹痛、黄疸、肝功能不良.结论 为防止在腹腔镜胆囊切除术中损伤右肝管及右副肝管,应熟悉胆管变异的各种类型、正确解剖胆囊三角、合理应用术中胆道造影、困难病例术后放置腹腔引流管及术后剖视胆囊等多种方法相结合.不同类型的胆道损伤处理上应分别对待.     

腹腔镜胆囊切除术损伤副肝管的预防和处理

我院1993-2003年行腹腔镜胆囊切除术（LC）6000余例，损伤副肝管7例，现报告如下。     

腹腔镜胆囊切除术中右肝动脉损伤5例处理体会

目的探讨腹腔镜胆囊切除术(LC)中引起右肝动脉损伤的原因及诊断和处理方法。方法对我院2000年1月至2013年12月行腹腔镜胆囊切除术6 000余例中5例发生右肝动脉损伤的患者资料进行回顾性分析。结果本组5例,均为术中发现并及时进行处理。术后2例感觉肝区轻微胀痛不适;1例发生低热,但数天后就很快消失。术后2~3 d抽血行肝脏功能检查,均示有不同程度的肝功能损害的发生,但术后1个月内复查均全部恢复正常。1例胆道支撑的T管于术后6个月后拔除。所有病例术后均获随访6~24个月以上(平均20.4个月),均恢复良好,无并发症的发生。结论在LC术中发生右肝动脉的损伤,往往是多种因素共同导致的结果。术中发现、诊断并及时处理是最为常见的方式。对于具体的处理方式,应根据损伤的部位、类型、设备及技术条件、局部组织条件、术前肝脏功能状况、有无合并胆管损伤及胆管损伤的部位等来进行个体化的选择。     

腹腔镜胆囊切除术中预防右肝动脉损伤经验总结

目的探讨腹腔镜胆囊切除术(LC)中右肝动脉损伤的教训及经验总结。方法回顾性分析2012年1月至2017年1月郴州市第一人民医院13例LC术中伴有右肝动脉解剖变异患者的临床资料。结果 13例患者中,3例右肝动脉损伤,其中1例大出血;10例患者避免了右肝动脉损伤。结论 LC术中要熟悉胆囊三角的生理及病理状态下的变异解剖,并遵循"胆囊后三角"优先原则,才能避免右肝动脉的损伤。     

腹腔镜胆囊切除术中右肝动脉损伤的预防体会

目的:探讨腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)中右肝动脉损伤的原因及预防措施。方法:2000年1月至2013年12月行6 000余例LC,其中5例发生右肝动脉损伤。结果:本组5例均为术中发现并及时处理。术后2~3 d抽血行肝脏功能等检查,均提示胆红素及酶学指标等有不同程度的升高,但术后1个月内复查均恢复正常。术后2例感觉肝区有轻微胀痛不适;1例发生低热,数天后消失。1例胆道支撑的T管,于术后6个月后拔除。术后患者均获随访,随访6~24个月,平均(20.4±2.1)个月,患者均恢复良好,无并发症发生。结论:LC术中发生右肝动脉损伤往往是多种因素共同作用的结果。有效避免或降低LC术中右肝动脉损伤的发生,关键是术者应时刻保持发生右肝动脉损伤的警惕性,处处小心、步步提防,并根据手术经验采用不同的方式进行预防,术中必须严格遵循LC的相关操作原则。     

腹腔镜胆囊切除术中围肝门部管道少见变异的处理

目的研究腹腔镜胆囊切除术（LC）中围肝门部少见胆道和血管解剖变异及胆管和血管损伤的防治。方法1992—2006年，南方医科大学珠江医院在LC中对5例围肝门部管道少见变异进行了解剖及处理。均在气管插管全麻下，人工CO2气腹，采用“三管-孔-脏器”的显露方法，解剖围肝门部管道及胆囊切除。结果右肝管、肝右动脉及胆囊动脉变异1例，双胆囊管1例，变异的胆囊动脉及病理的胆囊管1例，异常的胆囊动脉和胆囊管合并迷走胆管1例，胆总管、肝总管、门静脉异常1例，均成功进行了胆囊切除手术，未发生血管及胆管损伤。结论应加强LC术中对异常胆道变异的认识和处理水平，对减少并发症具有非常重要的意义。     

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.     

Bile duct injuries during laparoscopic cholecystectomy: management and outcome

The aim of this study is to analyze our experience with the management of bile duct injuries (BDIs) following laparoscopic cholecystectomy (LC). From 1996 to 2004, 21 patients with BDI after LC were treated in our department. The BDIs were graded according to the classification of Strasberg. Ten patients had minor BDI. Minor injuries were classified as A in six and D in four patients. In three patients, endoscopic retrograde cholangiopancreatography sphincterotomy and stent placement was adequate treatment. Six patients required laparotomy and bile duct ligation or suturing, and one patient underwent laparoscopy with additional ligation of a duct of Luschka. Eleven patients had major BDIs. These injuries were classified as E1 in two, E2 in three, E3 in four, and E4 in two patients. Among the patients with a major BDI, Roux-en-Y hepaticojejunostomy was performed. After a median follow-up of 69.45 months, no evidence of biliary disease has been detected among our patients. BDIs should be managed in a specialist unit where surgeons skilled to perform such repairs should undertake definitive treatment. Roux-en-Y hepaticojejunostomy is the procedure of choice in the management of major BDIs as it is accompanied by satisfactory results.     

Bile duct injuries during laparoscopic cholecystectomy

Surgical Endoscopy -     

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     

Uncommon left hepatic duct injury during laparoscopic cholecystectomy

Laparoscopic cholecystectomy is currently the gold standard in the treatment of symptomatic gallstones but has been shown to have a higher incidence of biliary tree lesions (0.3-1%) compared with reported traditional open approaches. Loss of three-dimensional view and of depth perception is the main limit of the laparoscopic approach, especially if particular risk factors are associated (e.g., postinflammatory fibrosis, anatomic variations). Moreover, inadequate training may justify the increase of biliary tract lesions. The authors describe a unique case of left hepatic duct clipped without section of the duct itself during an otherwise "easy" operation. At the reintervention, because of the favorable local condition, a reconstruction was possible after a small duct resection with a ductal-hepatic anastomosis over a T-tube. This was removed after 8 months because of the good patency of the biliary tree and the absence of cholestasys. A long-term follow-up is mandatory for a complete functional evaluation.     

The role of hepatic resection in the management of bile duct injuries following laparoscopic cholecystectomy

The creation of a specialized hepatobiliary surgery unit at our medical center has resulted in referral of 16 patients with bile duct complications following laparoscopic cholecystectomy over the last 18 months. No patient required conversion to open cholecystectomy. Although no injury was recognized at the time of surgery, 15 of 16 patients became symptomatic within the first 30 days. Two patients died from sepsis and multisystem organ failure after protracted hospital courses. Endoscopic retrograde cholangiopancreatography and/or percutaneous transhepatic cholangiography determined diagnosis and level of injury. Six of seven patients with cystic duct leak underwent successful endoscopic stent placement and one patient sealed spontaneously after percutaneous drainage of a large biloma. Nine patients required surgery that included hepaticojejunostomy (five), T-tube insertion and drainage of abscess (two), or segmental hepatic resection (two). Timely recognition of bile duct complications following laparoscopic cholecystectomy is critical to a successful long-term outcome. Although the majority of cystic duct leaks can be managed with endoscopic stenting, patients with ductal injuries require hepaticojejunostomy. Segmental liver resection may serve an important role in the management of carefully selected patients with high intrahepatic injuries to avoid long-term transhepatic stenting and complications such as episodic cholangitis and late stricture formation.