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。     

腹腔镜胆囊切除术胆道损伤的临床分析

目的 总结腹腔镜胆囊切除术胆道损伤的原因、预防措施、诊断及处理方法.方法 回顾分析我院从2008年1月～2013年1月处理的14例腹腔镜胆囊切除术胆道损伤的临床资料.结果 在14例患者中,A型（3例）经闭合离断的小胆管＋腹腔引流术治疗,C型（1例）和D型（5例）经肝胆管的修补＋T管引流术＋腹腔引流术治疗,E1型（3例）和E3型（1例）经肝管-空肠Roux-en-Y吻合术＋腹腔引流术治疗,E4型（1例）经融合左右肝管后再行的肝管-空肠Roux-en-Y吻合术＋腹腔引流术治疗.14例患者术后随访6～60月,均恢复良好.结论 胆道损伤是腹腔镜胆囊切除术的严重并发症,我们在了解其主要原因的同时应尽力避免损伤,一旦出现需及时正确处理,以达到满意的预后.     

腹腔镜胆囊切除术中右肝管分支损伤的预防和治疗(附7例分析)

目的:探讨腹腔镜胆囊切除术(LC)中右肝管分支损伤的预防和治疗。方法:回顾分析本院近4年LC术中发生之右肝管分支损伤的诊断和治疗过程及随访情况。结果:2001年5月至2005年4月,我院行LC术中发现或术后发生胆漏、经造影证实为右肝管分支损伤者共7例,其中男2例、女5例。7例均属选择性手术,其中6例呈胆囊周围慢性炎症,粘连明显,5例在术中放置了双腔引流管,术后发现有胆汁引出。另2例系在术中发现于胆囊管切断后,肝面有胆汁溢出;当即中转开腹,行术中造影,发现为右肝管分支畸形受损,直径分别为0.3cm和0.4cm,予对端吻合;置T管作为内支撑,经胆总管引出。5例在术中放置双套引流管的病例中,1例因每日持续有20～100ml胆汁引出,于术后3个月行右肝管鄄空肠Roux鄄en鄄γ吻合,吻合口直径达1cm;4例分别在术后引流1～3个月后自行闭合,并无任何临床症状,肝功能无异常。2例在术中放置内支撑者,于术后9个月拔除T鄄管,恢复良好。结论:右肝管分支的损伤往往与胆囊三角的慢性炎症程度、胆道系统的解剖变异、手术操作不当等因素有关。对术后发现胆漏者,经通畅的引流治疗1～3个月后,大部病例可以治愈,不需进行第2次手术,对引流超过3个月不愈者,需再次手术。     

腹腔镜胆囊切除术致胆管损伤的诊治体会(附22例报告)

目的 探讨腹腔镜胆囊切除术(LC)中胆管损伤的预防和处理。方法 回顾性分析LC胆管损伤22例的特点、诊断、治疗及效果。结果 本组22例均行胆管空肠Roux—en—Y吻合，其中8例行肝门部胆管成形术，3例行中肝叶切除。22例于术后1年、3年随访未出现胆管狭窄、黄疽复发及胆管炎症状。结论 预防胆管损伤是关键，其处理应根据发现时间、部位、类型等选择不同的方法。     

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.     

腹腔镜胆囊切除致胆管损伤5例

目的 探讨LC致胆管损伤的原因。方法 回顾性地分析了开展LC以来遇到的5例胆管损伤的具体原因,总结了防止LC致胆管损伤的几点经验。结果 5例中2例于术中发现,分别行“T”管支架引流和端端吻合“T”管支架引流,痊愈而无后遗症。另3例分别行右肝管空肠Roux-en-Y吻合和肝门腔肠Roux-en-Y吻合,其中2例发生逆行感染。结论 LC致胆管损伤最主要的原因并非是由于解剖异常,人为因素、电凝或电钩的盲目使用才是最主要的原因。     

腹腔镜胆囊切除术后并发胆漏11例分析

目的探讨腹腔镜胆囊切除术后并发胆漏的原因、治疗原则及如何降低腹腔镜胆囊切除术后并发胆漏。方法总结并回顾分析腹腔镜胆囊切除术并发胆漏11例患者的临床资料。结果根据胆漏的原因及胆漏量决定治疗方案,所有患者经保守治疗或再次手术治疗均治愈。结论术中应注意解剖变异、操作仔细;术后及时缜密的观察、护理和采取针对性的治疗方法可减少胆漏的发生及避免胆漏后引起严重的并发症。     

胰管塑料支架预防ERCP术后胰腺炎的临床应用

目的 探讨胰管塑料支架预防内镜下逆行性胰胆管造影（ERCP）术后胰腺炎的临床效果。 方法 对我院2009年10月~2010年11月期间37例胆管炎或胆管结石患者在ERCP术中胆管插管困难患者的临床资料进行回顾性分析。这些患者均采用胰管括约肌小切口,并置入胰管塑料支架,观察是否并发术后胰腺炎或其他并发症。结果 在接受ERCP的37例患者中,3例出现高淀粉酶及高脂肪酶血症,其中1例淀粉酶高于正常值的3倍,余两例淀粉酶值分别为132和312 IU/l,脂肪酶324和523 IU/l。72小时后复查,上述结果均恢复正常。患者无腹痛,恶心呕吐等症状,胰腺周围无渗出或假性囊肿的出现。术后3~4周,电子胃镜下取出支架。除2例支架轻度外移1.0cm外,其余均放置良好,未见堵塞。结论 ERCP胆管插管困难患者放置胰管塑料支架可以预防术后胰腺炎的发生。     

Routine versus selective intraoperative cholangiography during laparoscopic cholecystectomy

Background Routine use of intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) is a matter of debate. Methods Data from 2,130 consecutive LCs and patients’ follow-up during 9 years were collected and analyzed. During the first 4 years of the study, 800 patients underwent LC, and IOC was performed selectively (SIOC). Thereafter, 1,330 patients underwent LC, and IOC was routinely attempted (RIOC) for all. Results In the IOC group, 159 patients met the criteria for SIOC, which was completed successfully in 141 cases (success rate, 88.6%). Bile duct calculi were found in nine patients. All other patients with no criteria or failed SIOC were followed, and in nine patients retained stones were documented. Thus, the incidence of ductal stones was 1.1% and sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) for the detection of ductal stones were 50, 100, 98.6, and 100%, respectively. In the RIOC group, IOC was routinely attempted in 1,330 patients and was successful in 1,133 (success rate, 90.9%; p = 0.015). Bile duct stones were detected in 37 patients (including 14 asymptomatic stones). In two cases, IOC failed to reveal ductal stones (false negative). There was no false-positive IOC. Therefore, with RIOC policy, the incidence of ductal stones, sensitivity, specificity, NPV, and PPV were 3.3, 97.4, 100, 99.8, and 100%, respectively (significantly higher for success rate, incidence, sensitivity, and NPV; p < 0.05). Abnormal IOC findings were also significantly higher in the RIOC group. Common bile duct injury occurred only in the SIOC group [two cases of all 2,130 LCs (0.09%)]. Conclusion RIOC during LC is a safe, accurate, quick, and cost-effective method for the detection of bile duct anatomy and stones. A highly disciplined performance of RIOC can minimize potentially debilitating and hazardous complications of bile duct injury.     

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.     

Laparoscopic cholecystectomy: early and late complications and their treatment

Summary Laparoscopic cholecystectomy gained wide acceptance as treatment of choice for gallstone disease and cholecystitis. With this new technique, not only did the new era of minimal invasive surgery begin, but also the spectrum of complications changed. Laparoscopy-related complications such as access injuries and procedure-related problems are discussed in our article. Typical mishaps are reviewed according to the literature. Set-up of the pneumoperitoneum (morbidity up to 0.2%); bleeding—from trocar sites and vascular injury (mortality up to 0.2%); biliary leaks and bile duct injuries are the main topics in this article (still on a level of 0.2%–0.8%). Aetiology, diagnosis and treatment are discussed, and an overview of the most cited classifications of bile duct injuries is summarised graphically. Finally, bowel injuries as a specific complication in laparoscopy are discussed (incidence up to 0.87%).Conclusion Careful selection of patients, the knowledge of typical procedure-related complications, and their best treatment are the key points for a safe laparosopic cholecystectomy.     

Long-term results of major bile duct injury associated with laparoscopic cholecystectomy

Background: Major bile duct injury (MBDI) is the most serious complication associated with laparoscopic cholecystectomy (LC). This study reports on long-term outcomes and clinical factors which predicted the outcome of 25 patients with LC-associated MBDI. Methods: Twenty-five consecutive patients receiving either primary (n = 11) or redo (n = 14) biliary reconstructive surgery at Cathay General Hospital for LC-associated MBDI were prospectively followed for 2 to 10 (mean, 4.5) years to assess their long-term outcomes. Twelve clinical factors relevant to their outcomes were analyzed. Results: There was no mortality. Although the 1-year postoperative results were successful in 23 patients (92%), the mid- to long-term outcomes were successful in only 17 patients (68%). Eight patients (32%) developed biliary strictures at an average of 3.3 years postoperatively and required subsequent reoperation or biliary stenting. Statistical comparison of 12 risk factors between the successful and unsuccessful groups revealed that two were significant, namely, repair performed by a nonreferral surgeon (p = 0.02) and repair at a stage with recent active inflammation (p = 0.04). A serum alkaline phosphatase level greater than 400 IU in the sixth postoperative month was highly correlated with long-term nonsuccess (p = 0.01). Conclusions: Only 68% of patients with LC-associated MBDI who underwent reconstructive surgery at our institution had long-term success. A serum alkaline phosphatase level above 400 IU in the sixth postoperative month was predictive of nonsuccess. For better long-term results, repair should be performed by the referral surgeon at a stage without coexisting active inflammation.     

Medicolegal claims following laparoscopic cholecystectomy in the UK and Ireland

INTRODUCTION

The causes and outcomes of medicolegal claims following laparoscopic cholecystectomy were evaluated.

SUBJECTS AND METHODS

A retrospective analysis of the experience of a consultant surgeon acting as an expert witness within the UK and Ireland (1990–2007).

RESULTS

A total of 151 claims were referred for an opinion. Sixty-three related to bile duct injuries and four followed major vascular injury. Bowel injury resulted in 17 claims. A postoperative biliary leak not associated with a bile duct injury was responsible for 25 claims. Other reasons for claims included spilled gallstones, port-site herniae, haemorrhage and other recognised complications associated with laparoscopic cholecystectomy. Twelve of the claims are on-going, two went to trial, 79 (52%) were settled out of court and 58 (38%) were discontinued after the claimants were advised that they were unlikely to win their case. Disclosed settlement amounts are reported.

CONCLUSIONS

Bile duct and major vascular injuries are almost indefensible. The delay in diagnosis and (mis)management of other recognised complications following laparoscopic cholecystectomy have also led to a significant number of successful medicolegal claims.     

Laparoscopic subtotal cholecystectomy as an alternative procedure designed to prevent bile duct injury: Experience of a hospital in northern China

Purpose  Experience and advances in laparoscopic techniques have made laparoscopic subtotal cholecystectomy (LSTC) a feasible option even in complex procedures. We report our experience of performing LSTC in the management of complicated cholecystitis. Methods  Among 1558 patients scheduled to undergo laparoscopic cholecystectomy (LC) in our institute between July 2004 and December 2007, 48 underwent LSTC for complicated cholecystitis. We describe our tailored approach and the techniques we used to accomplish this. Results  All 48 patients underwent retrograde cholecystectomy. Twenty (41.6%) required an additional port (the fourth port) to obtain adequate exposure of the hilum, 39 (81.3%) required suturing of the gallbladder infundibular remnant, and 4 (8.33%) experienced local complications. The mean operative time of LSTC was 61.7 ± 17.5 min, the estimated operative blood loss was 72.0 ± 32.8 ml, the time to resume oral intake was 27.8 ± 14.9 h, and the mean postoperative hospital stay was 4.5 ± 1.3 days. There was no bile duct injury or mortality in this series. Conclusion  Laparoscopic subtotal cholecystectomy is a safe and feasible alternative to conversion to open surgery during difficult laparoscopic cholecystectomy for patients with complicated cholecystitis. However, we emphasize that only experienced laparoscopic surgeons should perform this procedure when complete removal of the gallbladder is not possible.     

腹腔镜胆囊切除术中胆囊床胆管损伤的处理

目的探讨预防及处理腹腔镜胆囊切除术（laparoscopic cholecystectomy，LC）时胆囊床胆管（包括右肝管分支及迷走胆管）损伤的对策。方法回顾性分析1997年1月～2004年12月2032例LC中15例胆囊床胆管损伤的临床特征、处理方法及效果。结果5例为慢性结石性胆囊炎急性发作，10例为慢性结石性萎缩性胆囊炎。8例右肝管分支损伤，7例迷走胆管损伤。8例用钛夹夹闭损伤胆管，5例缝合损伤胆管，另2例由于裂口较大且靠近右肝管主干而行开腹胆管修补术。术后胆漏1例，引流5d后痊愈。随访半年～3年，平均23个月，症状消失，无黄疸及胆管炎等并发症发生。结论预防胆囊床处胆管损伤的关键是紧贴胆囊壁剥离胆囊，术中及时发现并采用恰当的处理方法可获得较好的结果。     

应用“胆总管窗”行腹腔镜胆囊切除术

目的探讨“胆总管窗”在腹腔镜胆囊切除术中的应用价值。方法选择2009年6月1日至2009年10月31日期间行腹腔镜胆囊切除的患者55例,以“胆总管窗”为标志行腹腔镜胆囊切除术,观察术中“胆总管窗”以及肝总管和胆总管在肝门与“胆总管窗”连线的出现率,分析肝总管、胆总管、胆囊管与肝门至“胆总管窗”连线的关系。结果“胆总管窗”的出现率为92．7％（51／55）,98％肝总管和胆总管位于肝门与“胆总管窗”的连线上,并能被显露,胆囊管位于此线右侧。在胆囊急性炎症发作时,肝十二指肠韧带炎症水肿明显,大多数患者仍能观察到“胆总管窗”。结论运用“胆总管窗”作为解剖标志,在肝门与“胆总管窗”的连线上显露肝总管和胆总管,能够很好地显示肝总管、胆总管、胆囊管之间的关系。以“胆总管窗”为标记进行操作,有助于降低腹腔镜胆囊切除术中胆管损伤的发生率。     

腹腔镜胆囊切除术后胆漏的原因分析和防治

目的　探讨腹腔镜胆囊切除术 (laparoscopiccholecystectomy ,LC)后胆漏的原因和防治。　方法　对 1993年 10月～ 2 0 0 3年 10月十年中 36 2 6例腹腔镜胆囊切除术后并发 9例胆漏进行回顾性分析。　结果　 6例经腹腔引流术 ,其中 1例胆囊管残端漏者联合内镜下鼻胆管引流术治疗 ;腹腔镜探查 3例 ,1例胆囊管残端钛夹夹闭不全者在腹腔镜下重新夹闭成功 ,2例胆管损伤者中转开腹。 9例均治愈出院 ,随访 1～ 9年 ,平均 3 7年 ,无胆道并发症发生。　结论　腹腔镜胆囊切除术后胆漏应早期诊断和及时治疗 ,肝下放置引流管有重要价值 ,但关键在预防。     

腹腔镜胆囊切除术2 800例术中胆囊床的处理

目的探讨腹腔镜胆囊切除术（1aparoscopic cholecystectomy，LC）中胆囊床的处理方法。方法回顾分析我院1997年9月一2005年8月2800例LC的临床资料。结果在胆囊床的处理过程中，有2570例采用常规方法处理，46例采用非常规方法，余184例采用常规与非常规相结合的方法处理。12例胆漏，经充分引流治愈。26例胆囊床出血，1例术后2h行剖腹探查，余25例为术中出血。结论LC术中胆囊床的处理应根据术中所见胆囊床的具体类型来决定，一旦发生胆漏或出血等并发症，不应盲目处理，需视具体情况采取相应措施。     

腹腔镜胆囊切除术胆管损伤的特点及诊治

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。副肝管损伤儿例，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OC（开腹胆囊切除术）更易发生胆管损伤，且损伤更为隐蔽、复杂，处理困难，预后差。首先要争取早期发现，尤其是术中及时发现，根据情况选择恰当的处理方式，避免废弃Oddi括约肌用细薄的正常胆管行胆肠吻合。有分期手术指征的，不勉强行一期手术。胆管吻合后须T管支撑至少6个月。对副肝管的处理须谨慎，不能仅根据其直径粗细作决定，有条件的医院应行术中胆道造影，引流范围小的副肝管才能结扎处理，否则应予修复或重建。不能行术中胆道造影或修复重建困难的，建议先采取副肝管近断端插管外引流的方法。     

腹腔镜胆囊切除术胆道损伤的原因及处理

目的 分析腹腔镜胆囊切除术（ LC ）胆管损伤的原因及处理措施.方法 对自 2004 年1 月至 2011 年 12 月行 LC 患者 3156 例进行分析,发生胆道损伤 6 例,术中发现 4 例,术后胆漏发现 2 例.其中,胆囊床胆漏 1 例,胆总管横断 1 例,肝总管钛夹不全夹闭 1 例,右肝管夹闭并前壁剪开1 例,副右肝管夹闭横断 1 例,电钩损伤右肝管前壁 1 例.胆囊床胆漏及副右肝管夹闭未做处理 2 例;胆管对端吻合并置 T 管支撑引流 2 例;取出生物夹,行 T 管支撑引流 1 例;术后胆瘘 1 例,术后 7 d 再次开腹发现右肝管前壁坏死脱落,行坏死组织清除,T 管支撑引流,大网膜覆盖.结果 胆囊床漏胆及副右肝管夹闭未做处理 2 例术后随访 5 年,未发现肝脏萎缩及胆道狭窄;4 例行 T 管支撑引流者,术后随访 17 ～ 60 个月,平均 34 个月,未出现任何不适,无胆管狭窄及其他并发症.结论 术者对 LC 潜在危险性缺乏足够重视,经验不足或者盲目自信,镜下不能正确判断变异解剖关系,器械使用不当,是发生胆管损伤的根本原因.严格掌握手术适应证,强化操作训练,把握中转开腹的时机,可减少胆管损伤的发生.