TECHNIQUE AND RESULTS OF LAPAROSCOPIC CHOLEDOCHOTOMY FOR THE MANAGEMENT OF BILE DUCT CALCULI

Laparoscopic choledochotomy has been performed in 50 patients to remove common bile duct calculi demonstrated on routine operative cholangiography at the time of laparoscopic cholecystectomy. The patients ranged from 16 to 91 years old. One patient died, giving a mortality of 2%. At postoperative T-tube cholangiography, retained stones were demonstrated in three patients (6%) with all stones being removed using a choledochoscope via the T-tube track. Laparoscopic common bile duct exploration via a choledochotomy is a feasible and effective method to manage common bile duct calculi demonstrated during laparoscopic cholecystectomy.     

腹腔镜胆总管切开取石T管引流术

目的探讨腹腔镜胆总管切开取石T管引流术治疗胆总管结石的可行性。方法60例胆囊结石合并胆总管结石行腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）、胆总管切开取石T管引流术。结果60例手术均获成功,无中转开腹手术。手术时间90～180min,平均110min;术中出血量10～50ml,平均20ml。2例术后胆漏,保守治愈;6例胆道残余结石术后胆道镜取净。53例（随访率88．3％）随访2～33个月,平均13．2月,均无腹痛,发热,黄疸发作。结论LC、胆总管探查术治疗胆囊结石合并胆总管结石技术可行。     

腹腔镜胆总管探查治疗胆囊切除术后复发或残留胆总管结石的临床疗效

目的:探讨腹腔镜下胆总管探查(LCBDE)治疗胆囊切除术后复发或残留胆总管结石的临床疗效。方法:回顾性分析2012年4月—2015年6月52例行LCBDE治疗的胆囊切除术后复发或残留胆总管结石患者临床资料。结果:52例患者中成功完成LCBDE 48例(92.3%),其余4例均因腹腔粘连致密而中转开腹手术。48例患者术中放置T管15例,行胆总管一期缝合33例;手术时间(102.6±19.5)min,术中出血量(38.6±12.7)m L,术后住院时间(4.2±2.5)d;术后发生轻微胆汁漏2例,拔T管后胆汁性腹膜炎1例,均经保守治疗痊愈;术后胆总管残留结石1例,于术后6周经T管窦道胆道镜下网篮取石治愈。结论:LCBDE治疗胆囊切除术后复发或残留胆总管结石成功率高,且微创、恢复快,推荐临床应用。     

腹腔镜下胆总管探查术治疗胆囊结石并胆总管结石(附84例报告)

目的 :探讨用腹腔镜行胆总管探查术治疗胆石症的微创意义及可行性。方法 :分析 84例胆囊结石并胆总管结石或胆囊切除术后胆总管结石患者运用腹腔镜下胆囊切除和 (或 )胆总管切开取石术的临床资料。结果 :84例胆石症患者均在腹腔镜下完成手术 ,其中 76例行胆囊切除并胆总管切开取石T管引流术 ,8例行胆总管一期缝合术 ,术后未发生并发症。结论 :腹腔镜胆囊切除并胆总管探查术治疗胆囊结石并胆管结石技术上是安全、可行的 ,治疗效果肯定 ,微创意义明显。     

腹腔镜胆总管切开取石T管引流术治疗胆囊结石并胆总管结石

目的探讨腹腔镜下胆囊切除胆总管探查术式治疗胆囊结石并胆总管结石的微创意义及可行性。方法分析76例胆囊结石并胆总管结石运用腹腔镜下胆囊切除胆总管切开取石术的术式及病例资料特点。结果所有患者均行腹腔镜胆囊切除胆总管探查T管引流术(LCH-TD),无中转开腹病例、无手术并发症。结论腹腔镜胆囊切除胆总管探查术是治疗胆囊结石并胆总管结石的标准术式,技术上是可行的,微创效果肯定。     

Nontraumatic perforation of the bile duct treated with laparoscopic surgery

Nontraumatic perforation of the bile duct (NPB), which has also been reported as spontaneous perforation of the bile duct, is a disease in which spontaneous perforation occurs in the wall of the extrahepatic or intrahepatic duct without any traumatic or iatrogenic injury. Although NPB in adults is extremely rare, we have treated two such patients using a laparoscopic technique. Both cases presented with intra-abdominal abscesses associated with common bile duct stones, and laparoscopic surgery for those conditions was initially performed. During the procedure, NPB was identified in the right intrahepatic duct in one case and in the left intrahepatic duct in the other case. Laparoscopic surgery consisting of common bile duct exploration, T-tube placement, cholecystectomy, and abscess drainage was safely performed in both cases. Both patients eventually recovered without major complications. Although NBP is an uncommon disease, it can be treated successfully with a laparoscopic procedure.     

7 小儿胆石症的诊断与治疗

目的探讨小儿胆石症的病因、诊断及治疗方法。方法分析22例小儿胆石症的临床资料,20例行手术治疗,2例行非手术治疗。14例行胆囊切除术(其中8例行腹腔镜胆囊切除术),3例行胆总管切开取石、T管引流术,2例行胆囊切除、胆总管探查、T管引流术,1例行胆总管囊肿切除、肝总管空肠Roux-en-Y吻合术。结果18例经手术治疗后症状消失,术后1例出现胆瘘,经引流后痊愈,1例右肝管内结石残留。18例(81.8%)得到随访,4例失访。随访5个月至7年,患儿生长发育正常,3例偶有腹痛、腹胀,1例行二次胆总管切开取石术,术后恢复顺利。行非手术治疗的2例病人经保守治疗后近期症状缓解,其中1例症状反复发作。结论对有腹痛者首选B超检查,对有胆总管扩张或黄疸的患儿结合CT检查可提高正确诊断率;症状明显的胆石症应早期手术治疗;腹腔镜可作为胆囊切除的首选治疗方法。     

Digital subtraction cholangiography: a new technique for visualising the common bile duct during cholecystectomy.

Operative cholangiography is for most surgeons a routine part of every cholecystectomy. Computerised digital subtraction angiography was adapted for operative cholangiography using a portable machine. After cannulation of the cystic duct the background image was subtracted before injecting contrast. Only the contrast within the bile duct appears on the monitor and resolution is high. A permanent record was made on 10 X 10 cm spot films. Eighteen pre-exploratory cholangiograms were performed using this method. In 12 no stones were demonstrated on digital subtraction cholangiography (DSC), nor were there clinical indications of common bile duct stones. These patients underwent cholecystectomy only. Stones were demonstrated on DSC in 3 patients and all had stones at exploration of the common bile duct (CBD). Three patients had no stones demonstrated on DSC but were explored on clinical grounds. No stones were found. Postoperative T-tube cholangiograms confirmed the absence of stones in 5 patients. A retained stone was present in one patient who had not had a postexploratory examination at operation and was not related to the use of this cholangiographic technique. DSC combines the benefits of image intensification and still radiography and has been accurate in both predicting and excluding common bile duct stones.     

Transcystic common bile duct exploration in the management of patients with choledocholithiasis

Common bile duct stones are found in approximately 16% of patients undergoing laparoscopic cholecystectomy. If the diagnosis of choledocholithiasis is made at the preoperative workup, it is common practice to refer the patient for endoscopic retrograde cholangiography and endoscopic sphincterotomy. However, if the diagnosis is established during intraoperative cholangiography, the surgeon is confronted with a therapeutic dilemma-that is, the choice between laparoscopic common bile duct exploration, conversion to open surgery, or postoperative endoscopic sphincterotomy. We have opted to treat patients with choledocholithiasis in only one session during the laparoscopic cholecystectomy; we use the transcystic common bile duct exploration technique employing the choledochoscope. We report our early experience in terms of success of stone removal, operative time, morbidity and mortality, and length of hospital stay. From 1992 to 2002, we performed 350 laparoscopic cholecystectomies. Selective cholangiography was used in 105 patients (30%); 40 of them were found to have common bile duct stones, for an incidence of 11.4%. Among this group, we performed laparoscopic transcystic common bile duct exploration in all but six patients. Our success rate for stone removal was 94.1% (32 of 34 patients), with only two failures related to multiple stones and impaction at the ampulla, for a conversion rate of 5.8%. The mean operative time was 120 ± 40 minutes. The morbidity rate was 8.8%, and there were no deaths. Length of hospital stay was 24 to 48 hours. Mean recovery time was 7 days, and time to return to work was 15±3 days. We concluded that most of the patients with common bile duct stones found during laparoscopic cholecystectomy could be treated successfully by means of the transcystic technique with choledochoscopy, with no increase in morbidity or mortality and a shortened hospital stay and recovery time, similar to patients who undergo only laparoscopic cholecystectomy. On the basis of our results, we recommend that this method become the primary strategy in the great majority of patients with common bile duct stones found during intraoperative cholangiography. Presented at the Forty-Third Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, California, May 19–22, 2002 (poster presentation).     

Is surgical bile duct revision in choledocholithiasis still indicated?]

Endoscopic papillotomy with stone extraction is increasingly performed for the management of common bile duct stones either before cholecystectomy or as a sole procedure leaving the gallbladder in situ. We have therefore evaluated the method of operative common duct exploration. 94 cases with bile duct stones treated by cholecystectomy and common bile duct exploration were reviewed. The 30-day mortality was 2.1% with an overall morbidity of 19%. A retained stone was found on postoperative T-tube cholangiography in 6 patients and in all cases was removed percutaneously via the T-tube track. Patients were divided into three age groups (less than or equal to 60, 61-75, greater than 75 years). In each patient various risk factors were recorded. Correlation was made between age, risk factors and patient's morbidity. No correlation was found between age and morbidity. Patients with up to two risk factors had a morbidity of 10%. With three to four risk factors the morbidity increased to 19%, reaching 47% in patients with five and more risk factors. Cholecystectomy with common bile duct exploration is a safe procedure even in the elderly patient. Careful evaluation of risk factors is necessary. Endoscopic papillotomy with or without cholecystectomy should be considered in high risk patients.     

腹腔镜联合十二指肠镜治疗胆囊结石合并胆总管结石效果分析

目的 探讨腹腔镜胆囊切除术(LC)联合内镜Oddi括约肌切开取石术(EST)治疗胆囊结石合并胆总管结石的临床效果.方法 回顾性分析2003年5月-2009年6月,LC与EST联合治疗胆囊结石合并胆总管结石78例临床资料.首先经EST取出胆管结石,5 d内行LC.结果 EST成功76例(97%),失效2例,1例因胆管末端狭窄,开腹行胆肠吻合术治愈;1例胆总管结石直径1.6 cm,质硬,机械性碎石失败,开腹行胆总管切开取石T管引流术.76例腹腔镜手术成功,无明显出血、胆漏等严重并发症.结论 EST+LC联合治疗胆囊结石并胆总管结石具有创伤小、恢复快、并发症少及无需T管引流等优点,是一种安全有效的治疗方法.     

EST联合LC治疗胆囊结石胆总管结石

目的：探讨EST联合LC联合治疗胆囊、胆总管结石的可行性及优越性。方法：先行EST（经内镜十二指肠乳头括约肌切开术）取出胆总管结石,再行LC（腹腔镜胆囊切除术）,EST失败或不宜行EST者置ENBD（鼻胆管）再行LC+腹腔镜下胆道探查、胆道镜取石,或开腹行胆道探查术。结果：全组99例,91例LC术前EST取石成功,3例LC术后EST取石成功,3例EST取石失败。2例年龄小于15岁者未行EST改行LC+腹腔镜下经胆囊管胆道镜胆道探查取石。3例EST取石失败,改行腹腔镜下胆道探查胆道镜取石、胆总管一期缝合或T管引流+LC,或开腹胆道探查一期缝合胆总管未置T管（已置ENBD）。无严重并发症,患者均治愈出院。结论：EST联合LC联合治疗胆囊结石胆总管结石是安全、可靠的方法,软硬镜联合充分体现了“微创”治疗的优势。     

腹腔镜胆总管切开取石一期缝合术治疗胆总管结石53例分析

目的：探讨腹腔镜胆总管切开取石一期缝合术治疗胆总管结石的可行性及安全性。方法：回顾分析2009年12月至2012年8月为53例胆囊结石合并胆总管结石患者行腹腔镜、纤维胆道镜联合治疗的临床资料。腹腔镜胆囊切除联合胆总管切开,经胆道镜置入取石网篮取石,术毕一期缝合胆总管。结果：本组腹腔镜胆道镜联合胆总管探查取石术成功率98.1%（52/53）,1例中转开腹留置T管。手术时间平均（89.1±46.3）min,术中出血量平均（35±24.9）ml,术后平均住院（6.7±3.1）d,3例发生胆漏,1例再次手术。术后随访4个月～2年,发生残余胆总管结石1例。结论：在严格把握手术指征、认真术前影像学评价、术中熟练胆道镜操作、精准缝合的前提下,腹腔镜胆总管切开取石一期缝合术治疗胆总管结石是安全、可行的。     

腹腔镜胆总管探查术242例临床分析

目的为了探讨腹腔镜下胆总管探查术的临床应用效果。方法回顾性分析我院2007年6月~2016年6月242例腹腔镜下胆总管探查术的临床资料。术中行胆总管探查T管引流术170例,胆总管切开探查一期缝合42例,经胆囊管探查胆总管取石30例。结果本组242例患者中,手术时间70~260min,平均130min,术中失血30~460ml,平均150 ml。胆漏30例,28例经腹腔引流管引流4~7天治愈,2例形成腹腔局部积液经B超定位穿刺引流而治愈。肺部感染6例,胸腔积液4例,切口感染2例。20例术后行T管造影检查证实为胆管残余结石,经胆道镜1~4次取石后取净;2例患者胆道镜无法取出残余结石,经ERCP取出残余结石。术后第1d所有患者可下床活动,平均输液时间4~8d。结论腹腔镜下胆总管探查术是相对微创安全的手术,应根据患者具体情况采取个体化的术式。     

刮吸解剖法在急性胆囊炎腹腔镜胆囊切除术中的应用

目的探讨刮吸解剖法在急性胆囊炎腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）中的应用价值。方法2002年8月-2008年1月,借助腹腔镜多功能手术解剖器（laparoscopic Peng,s multifunctional operative dissector,LPMOD）应用刮吸解剖法对820例急性胆囊炎施行LC。对有胆道相对探查指征的158例（143例有胆总管扩张）行术中胆道造影,发现胆总管结石17例,其中14例完成腹腔镜下胆总管探查术（laparoscopic common bile duct exploration,LCBDE）。结果812例LC成功,8例中转开腹。LC平均手术时间55 min（25-120 min）,LC＋LCBDE平均手术时间95 min（80-130min）,术中平均出血量25 ml（0.5-80 ml）,术后平均住院5 d（3-9 d）。无胆管损伤、胆漏、术后出血等并发症。804例随访2-18个月,平均11个月,2例胆总管残余结石（1例行开腹胆总管切开取石,1例行EST取石）,其余患者未发现与手术相关并发症。结论在急性胆囊炎腹腔镜胆囊切除术中应用刮吸解剖法能有效防止术中胆道损伤,安全可靠,值得临床推广。     

LAPAROSCOPIC EXPLORATION OF INTRA- AND EXTRAHEPATIC BILE DUCTS AND T-TUBE DRAINAGE

Laparoscopic cholecystectomy (LC) has rapidly become the procedure of choice for the management of patients with gall-bladder stones. This contrasts with patients who have common bile duct and intrahepatic duct stones who still usually need an open operation. On the basis of experience of a number of LC by one surgeon and animal experiments, we have completed laparoscopic exploration of both intra- and extrahepatic ducts and T-tube drainage of 57 patients with intra- and extrahepatic bile duct calculi over 13 months during 1992–1993 with satisfactory results. The average operating time was 150min. with a range of 100 to 220 min. Most patients were mobile and on oral fluids within 24 h postoperative. Average hospital stay was 4 days. Retained stones were found via T-tube cholangiography in four patients (7%) and for each patient these were removed by fibre-optic choledochoscope 2 weeks postoperatively. Laparoscopic exploration of intra- and extrahepatic bile ducts is achievable by experienced surgeons and may be particularly helpful for patients who are not a good operative risk.     

Assessment of the common bile duct before cholecystectomy using ultrasound and biochemical measurements: validation based on follow-up.

The selective use of operative cholangiography with cholecystectomy is controversial. We have combined measurement of the serum bilirubin, alkaline phosphatase and alanine aminotransferase with ultrasound measurement of the bile duct diameter to assess the common bile duct before cholecystectomy. Direct contrast cholangiography was not performed if the results of these measurements were normal on the day before operation. There were 253 patients assessed in this way before laparoscopic cholecystectomy. Patients with known bile duct stones were excluded, but those with a previous history of jaundice, pancreatitis or abnormal liver function tests were included. In 47 cases abnormalities were found and X-ray cholangiograms were performed; only six patients were found to have bile duct stones. Follow-up of all 253 patients, including repeating the preoperative measurements after 12 months in 93, found only two patients with evidence that common duct stones had been missed and these two stones passed spontaneously. No bile duct injuries have occurred. We conclude that preoperative assessment of the bile duct using ultrasound and liver function tests safely obviates the need for 'routine' operative cholangiography.     

腹腔镜技术在肝外胆管结石治疗中的应用体会

目的探讨腹腔镜技术处理肝外胆管结石的意义。方法回顾性分析和总结2008年至2009年运用腹腔镜技术处理胆囊结石合并胆总管结石的12个病例资料。结果术前明确诊断10例,可疑合并有胆总管结石2例,均采用腹腔镜行胆囊切除+胆总管切开取石+胆道镜探查+T管引流术。12例手术顺利完成,手术时间85~150min,术中出血量30~100ml,术后第2天进流质,无胆漏、出血及T管引流口感染等并发症发生,平均住院时间4.5d,术后1个月T管造影无残留结石,再夹管3d后拔除T管。结论腹腔镜技术处理肝外胆道结石具有创伤小、恢复快、术后患者舒适度高等优点,且该技术安全可靠,配合胆道镜更能避免结石残留。     

澳大利亚微创胆道外科

目的 从20世纪末期以来,澳大利亚腹腔镜手术已经快速发展进步并且逐渐扩展到各个外科手术领域.一些外科医生也完成并发表了关于腹腔镜胆总管探查技术的报道.在本文中,作者介绍了目前澳大利亚的微创外科手术治疗胆管疾病的现状,包括：常规或选择性胆管造影;胰腺胆道疾病中ERCP的作用;腹腔镜胆总管探查术的手术技巧以及胆源性胰腺炎的治疗.作者还介绍了澳大利亚目前胆总管探查的现状,并且提到他们倾向于每例腹腔镜胆囊切除术都进行术中胆道造影.如果胆总管内发现小结石而且胆囊管足够粗,则进行经胆囊管的胆总管探查术.然而,如果狭窄的胆总管内有较大的结石,则进行术后ERCP治疗.作者还进一步介绍了胆道疾病相关的其他的微创治疗手术方法.总的来说,腹腔镜手术进行胆总管取石是可行和安全的.在有足够经验的医疗中心,这种手术方法可以常规使用.同时,成功进行腹腔镜胆总管探查术也需要多种方法综合进行.ERCP也没有被腹腔镜胆总管探查术所取代,而且成为一种重要的补充性的胆总管结石治疗方法.     

腹腔镜术中经胆囊管纤维胆道镜取石术的应用体会(附18例报告)

目的:探讨腹腔镜手术中应用胆道镜经胆囊管途径进行胆总管探查、取石的方法及临床价值。方法:对18例腹腔镜手术中经胆囊管途径行胆道镜胆总管探查、取石患者的临床资料进行回顾性分析。结果:经胆囊管途径胆道镜成功取出胆总管结石共17例,失败1例,取石成功94.4%(17/18)。结论:腹腔镜手术中应用经胆囊管途径取出胆总管内结石的方法安全可行,较之腹腔镜术中胆总管切开取石的方法创伤更小。