Bile Duct Injury After Single Incision Laparoscopic Cholecystectomy

Background:

The advancement and development of laparoscopic cholecystectomy revolutionized surgery and case management. Many procedures are routinely performed laparoscopically. Single incision laparoscopic surgery has been introduced with the hope of further reduction of scarring and possibly procedural pain. With no established technique for this procedure, the safety of single incision laparoscopic cholecystectomy has not been determined.

Methods and Results:

A 30-year-old man underwent single incision laparoscopic cholecystectomy for symptomatic cholelithiasis at an outside hospital. The operation was uneventful, and the patient was discharged home. The patient returned to the Emergency Department 4 days postoperatively, and a bile duct injury was diagnosed. A percutaneous drain was placed, and the patient was transferred to the Hepato-Pancreato-Biliary (HPB) service of a tertiary care center for definitive care. A delayed repair approach was used to allow the inflammation around the porta to decrease. Six weeks after injury, the patient underwent Roux-en-Y hepaticojejunostomy. The patient did well postoperatively.

Conclusion:

Although single incision laparoscopic surgery will play a prominent role in the future, its development and application are not without risks as demonstrated from this case. It is imperative that surgeons better define the surgical approach to achieve the critical view and select appropriate patients for single incision laparoscopic cholecystectomy.     

腹腔镜胆囊切除术中胆管损伤的防治对策

目的 探讨腹腔镜胆囊切除术(LC)中胆管损伤(BDI)的防治。方法 复习相关文献，结合临床实践，对LC中BDI的防治对策作总结分析。结果 随着LC的推广，BDI的发生有增高趋势，BDI发生的原因主要是胆囊三角区解剖不清、解剖变异、电热灼伤，也有思想麻痹和盲目自信引起的。LC术中采用钝性分离。少用电凝，熟悉局部解剖及其变异，切除胆囊前辨清胆总管与肝总管，必要时选择性应用术中胆道造影、腹腔镜超声、胆道闪烁扫描等辅助检查可预防BDI。BDI的处理应根据损伤类型和部位高低以及局部解剖组织的条件而可采用端端吻合、缺损修补、胆管十二指肠端侧吻合、肝胆管空肠端侧Roux—en-Y吻合，T管放置半年以上。结论 LC术中BDI应重视预防，发生后及时正确处理是改善预后的关键。     

复杂类型腹腔镜胆囊切除术中胆道损伤的预防与诊断

目的：介绍腹腔镜超声（LUS）在避免复杂类型的腹腔镜胆囊切除术（LC）中胆道损伤的作用。方法：177例LC因胆囊管真实性难以确定、三角区粘连或炎症、急性或萎缩性胆囊炎、可疑的胆道损伤等被界定为复杂的LC，并借助LUS显示的肝外胆管与胆囊壶腹、胆囊管之间的解剖关系施行LC。结果：在LUS辅助下顺利完成151例复杂的LC，另26例病人因LUS提示潜在胆道损伤危险及疑有胆道损伤而转为开腹。结论：通过LUS显示的肝外胆管及在术野中胆囊管、胆囊壶腹的参照下，术者可了解肝外胆系诸结构之间的解剖关系，由此避免胆道损伤。     

Prevalence of Bile Duct Injury Following Cholecystectomy

Introduction: A review of our experience with CAS in a non-academic hospital is presented. Materials and methods: A consecutive series of 18 CAS-interventions between 2003 and 2005 is studied retrospectively. Indication, medical history, preoperative carotid imaging, operative technique and results were studied for each patient.

Results: CAS was used 12 times in men and six (33.3%) times in women between 2003 and 2005. Five (27.8%) symptomatic stenoses, 12 (66.6%) asymptomatic stenoses and one (5.6%) arterio-venous fistula were treated. One permanent postoperative ipsilateral ischaemic neurologic deficit occurred (5.6%). The mean duration of hospital stay was 4.9 days (range: 2–9 days).

Conclusions: Our study shows that CAS is feasible in non-academic hospital settings, with acceptable early results. Participating in larger studies should confirm our results.     

腹腔镜胆囊切除术中胆管损伤的术中镜下修复

目的总结腹腔镜胆囊切除术（1aparoscopic cholecystectomy,LC）中胆管损伤的原因及术中镜下修复经验,探讨术中腹腔镜下修复胆道损伤的可行性。方法我院2001年7月～2012年9月共完成7例Lc术中胆管损伤的镜下修复,其中1例肝总管完全横断伤、1例胆总管完全横断伤及1例左肝管不完全横断伤、1例右肝管不完全横断伤、1例肝总管不完全横断伤采用胆管对端吻合T管引流术;1例左、右肝管汇合下方肝总管前壁直径10Inln缺损,采用转移胆囊管壁瓣修复肝管缺损T管引流术;1例肝总管不完全横断伤采用对端吻合,未留置T管。结果所有手术均获成功,无中转开腹。1例胆总管对端吻合病例术后胆漏,腹腔引流管引流20d愈合。余无并发症出现。6例放置T管引流者术后1年拔除T管。7例术后随访0．5～10年,平均3．2年,无腹痛、黄疸、发热,肝功能正常,B超未见胆管扩张。结论LC胆管损伤的术中修复可以在腹腔镜下顺利完成．     

Bile Duct Injuries Associated with Laparoscopic and Open Cholecystectomy: An 11-Year Experience in One Institute

Purpose Bile duct injury (BDI) represents the most serious complication of laparoscopic cholecystectomy (LC). The aim of this retrospective single-institution study was to evaluate the real incidence of BDI during laparoscopic and open cholecystectomy (OC) in a tertiary academic center in Athens, Greece.Methods Between January 1991 and December 2001, 3 637 patients underwent cholecystectomy in our department; as LC in 2 079 patients (LC group) and as OC in 1 558 patients (OC group). All the LCs were performed or supervised by five staff surgeons and all the OCs were performed or supervised by another five staff surgeons.Results There were 13 BDIs associated with LC (0.62%) and 6 associated with OC (0.38%) (P = 0.317). There was one death associated with BDI after LC. Only two (15.4%) of the BDIs associated with LC occurred within the proposed learning curve limit of 50 LCs per individual surgeon.Conclusion Laparoscopic cholecystectomy is safe and is not associated with a higher incidence of BDI than OC. Moreover, we did not find that the learning curve for LC affected BDI occurrence.     

A Multidisciplinary Approach to Major Bile Duct Injury Following Laparoscopic Cholecystectomy

Background and Objectives:

Many series describing the management of major bile duct injuries after laparoscopic cholecystectomy have been reported with satisfactory short-term results. However, the information of their prognosis with sufficient time-period follow-up is sparse.

Methods:

Sixteen consecutive patients with major bile duct injury following laparoscopic cholecystectomy were retrospectively reviewed, including six common bile duct transections, four bile duct perforations, and six hilar strictures but without perforation. With respect to the level of bile duct injuries, there were the following based on Bismuth''s classification: type 1 in six patients, type 2 in five patients, type 3 in three patients, type 4 in one patient, and type 5 in one patient. All patients received surgical management, interventional radiology and endoscopic treatment. The time periods of follow-up ranged from 37 to 72 months (mean, 52 months). The final results were rated as being excellent, good, fair, or poor, based on the criteria of symptoms, biochemical data, and radiology.

Results:

There was no procedure-related mortality. Ten of the 16 patients had either excellent or good results, two had fair results, and four had poor results. Of the latter four, the patients had been classified as Bismuth type 1, 3, 4, and 5, respectively, and all sustained a failed initial surgical repair.

Conclusions:

Using a multidisciplinary approach, 12 (75%) of the 16 patients attained a promising result through a long-term follow-up, while those with the higher biliary stricture and with an unsuccessful initial surgical repair had a disappointing outcome.     

腹腔镜胆囊切除术胆管损伤的处理

目的探讨腹腔镜胆囊切除术（laparoscopic cholecystectomy，LC）中胆管损伤的处理。方法回顾分析我院1992年3月-2006年10月8876例LC中16例胆管损伤的临床资料，其中胆总管横行剪断4例，电灼伤3例，胆总管部分撕裂伤4例，钛夹误夹5例。胆管裂口修补，T管支撑引流6例；游离两断端，行端端吻合，T管支撑引流3例；胆管空肠Roux—en—Y吻合5例；去肽夹2例。结果1例胆总管横行剪断后行胆管端端吻合，置T管支撑引流3个月，T管拔除3～5个月后因胆管狭窄，再次行胆管空肠Roux—en—Y吻合，术后未出现因胆管狭窄所引起阻塞性黄疸。2例因胆管空肠吻合口狭窄，分别于术后9、11个月再次行胆管空肠Roux—en—Y吻合，再手术后随访2～4年，未出现胆管炎症状、结石再形成。1例胆管完全性夹闭后行胆管空肠Roux—en-Y吻合术后胆道感染，反复发作。余12例均一次性临床治愈，其中10例随访3～4年，未出现任何不适。结论胆管损伤是LC的主要并发症，早期预防和积极处理胆管损伤是防止多次胆道手术的重要举措。     

腹腔镜超声技术在胆囊切除胆道探查术中的应用

本文旨在探讨腹腔镜超声技术在LC中的临床应用价值和开创腔镜诊治胆石症的新途径。320例LC病有常规行腹腔镜超声检查(LUS);50例行腹腔镜超声和术中胆管造影(LOC)对比研究。胆管结石采用ERCP/EST和腹腔镜胆囊切除胆总管切开探查取石T管引流或一期缝合术治疗。结果显示LUS平均检查时间15min,对胆道系统和血管系统扫描结果显示:胆囊和门静脉100％显像,肝胆管胆总管98％显像,胆总管未端86％显像,3％发现未预期胆管结石,发现10％胆囊管解剖变异;LUS和IOC对比结果显示LUS胆总管结石敏感性、特异性和总诊断正确率均优于IOC(分别为83％、98％、98％和76％、95％、95％),两者结合则高达100％。ERCP/EST成功率达90％,30例腹腔镜胆总管探查取石术平均手术时间3.5小时,25例置T管引流、5例一期胆管缝合,均获成功,未发生胆漏胆管损伤等并发症,术后残石者经T管胆道镜取石治愈。因此,LC中常规使用腹腔镜超声技术有助于判断胆道生理和病理解剖结构、防止发生胆管损伤;有助于发现或排除肝内外胆管结石、为胆管造影和胆道探查术提供重要指征,降低胆道残石和阴性胆道探查术。腹腔镜超声指导下的腹腔镜胆囊切除胆道探查取石T管引流或一期胆管缝合术安全可靠、为胆石症微创外科诊断和治疗开辟了一条新途径。     

胆囊切除术中胆总管钳夹结扎后及时松解的实验研究

目的探讨胆囊切除术中胆总管钳夹结扎后立即松解对胆总管损伤程度的影响。方法选取健康日本大白兔18只，按完全随机法均分成3组，即单纯胆囊切除组、胆囊切除＋胆总管横行结扎组（简称横行结扎组）和胆囊切除＋肝总管胆总管汇合部“Y”形结扎组（简称“Y”形结扎组），后两组结扎5min后松解。观察不同时间各组转氨酶、胆红素变化情况及胆管、肝脏的病理状况。结果术前12h、术后1、7d谷丙转氨酶、谷草转氨酶、总胆红素、直接胆红素及直接胆红素与总胆红素的比值，横行结扎组及“Y”形结扎组与单纯胆囊切除组比较差异无统计学意义（P〉0．05）；术后30和90d，上述各项指标横行结扎组及“Y”形结扎组与单纯胆囊切除组比较差异有统计学意义（P〈0．05），胆管和肝脏病理学检查也有明显变化。结论胆囊切除术中胆总管钳夹结扎后及时（5min）松解对胆总管近期影响不明显，远期可造成胆管狭窄、梗阻。     

困难型腹腔镜胆囊切除术中医源性胆道损伤的预防策略

目的总结后-前胆囊三角解剖入路法在困难型腹腔镜胆囊切除术(laparoscop ic chole-cystectomy,LC)中预防医源性胆道损伤的价值。方法在265例困难型LC术中应用联合解剖后-前胆囊三角入路法切除胆囊。结果260例顺利完成LC,中转开腹手术5例,原因为胆囊壶腹冰冻样粘连无法解剖出胆囊后-前三角3例,胆囊床肝中静脉属支祼露分破出血中转开腹缝合止血2例。另有2例术中胆囊床迷走胆管胆漏,镜下夹闭成功;术中出血3例予镜下止血满意,无胆道损伤病例。结论联合解剖后-前胆囊三角入路法对预防困难型LC术中医源性胆道损伤有一定的价值,是可供选择的安全有效果的手术方式之一。     

腹腔镜与内镜联合治疗胆囊结石合并胆总管结石的Meta分析

目的:采用循证医学方法对腹腔镜与内镜治疗胆囊结石合并胆总管结石的安全性和有效性进行客观分析.方法:计算机检索PubMed、Embase、Web of Science、Cochrane library和CNKI数据库,筛选出有效数据后采用Review Manager 5.3软件进行比较分析.结果:共纳入8篇文献,共有86...     

Long-term Outcome and Risk Factors of Failure after Bile Duct Injury Repair

Background  The real long-term outcome of a hepaticojejunostomy (HJ) to repair bile duct injury (BDI) is unclear, and the risk factors for repair failure are partially defined. Study Design  A retrospective, nonrandomized study of the long-term outcome of biliary reconstructions after major BDIs. All injuries occurred in association with cholecystectomy. Results  Twenty-nine patients were referred with complete transection of the common (n = 16), right (n = 5), or right sectoral (n = 4) hepatic ducts or of >1 major duct (n = 4) between October 2002 and January 2007. Mean follow-up was 24 months, range 12–60 months. Original repairs were “immediate” in 14, “delayed” (within 24–72h) in 5, and “elective” (after >8 weeks) in 10, and strictures developed in 9, 5, and 1 of those HJs, respectively. The surgical outcomes were significantly better when the intervention took place electively (p = 0.003). Original HJ repairs were done by a hepatobiliary surgeon (n = 23) or by a general surgeon (n = 6): the outcome was significantly better for the former (p < 0.001). Conclusions  The 51.7% incidence of strictures after BDI repair in this study was higher than reported in the literature, probably because of selection bias secondary to the referral pattern. The timing of repair and the surgeon’s expertise are significant risk factors of failure. This work was presented before the 25th National Congress of the Israel Surgical Society, Jerusalem, Israel, 2007 and before the 8th World Congress of the IHPBA, Mumbai, India, 2008.     

腹腔镜胆囊切除术中胆管损伤防治分析

目的探讨腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）术中胆管损伤原因,总结处理经验。方法回顾性分析1998年10月-2006年8月1 528例LC术中9例（0.59%）胆管损伤的资料。结果本组7例术中发现胆管损伤,4例予局部压迫处理,1例术中置入T管引流,2例中转开腹手术。另有2例术后出现胆汁性腹膜炎而二次手术,术中发现胆总管损伤,予T管支撑引流治愈。开展LC的前500例中发生胆管损伤6例（1.20%）,其中中转开腹手术2例（0.40%）;500例以后的LC,胆管损伤率为0.29%（3/1 028）,中转开腹率为0。结论LC术中胆管损伤多发生在复杂病理改变的病例,强化对解剖变异、高危病例及高危技术的认识是避免胆管损伤的关键;一旦发生LC术中不能良好处理的胆管损伤,及时中转开腹手术是理性的选择。     

Iatrogenic Combined Bile Duct and Right Hepatic Artery Injury During Single Incision Laparoscopic Cholecystectomy

Background:

Numerous recent reports describe the performance of laparoscopic procedures through a single incision. Although the feasibility of this approach for a variety of procedures is currently being established, little data are available regarding safety.

Case Report:

A 65-year-old female patient who was transferred from an outside institution had undergone a single incision laparoscopic cholecystectomy that resulted in biliary tract and vascular injuries.

Methods:

The patient was transferred with a known bile duct injury on the first postoperative day following single incision laparoscopic cholecystectomy. Review of her magnetic resonance imaging and percutaneous transhepatic cholangiogram studies showed a Bismuth type 3 bile duct injury. Hepatic angiogram demonstrated an occlusion of the right hepatic artery with collateralization from the left hepatic artery. She was initially managed conservatively with a right-sided external biliary drain, followed 6 weeks later by a Hepp-Couinaud procedure to reconstruct the biliary tract.

Conclusion:

As new techniques evolve, it is imperative that safety, or potential side effects, or both safety and side effects, be monitored, because no learning curve is established for these new techniques. In these initial stages, surgeons should have a low threshold to add additional ports when necessary to ensure that procedures are completed safely.     

腹腔镜胆囊切除术胆管损伤的护理

通过对７例腹腔镜胆囊切除术胆管损伤病人的护理，总结了腹腔镜胆囊切除术后加强对漏胆、腹腔感染、黄疸等胆管损伤的临床症状的观察，重点阐述了Ｔ形管的护理是胆管损伤重建手术后的护理重点。     

腹腔镜胆囊切除术预防胆管损伤的术式研究

目的探讨改良术式对腹腔镜胆囊切除手术预防胆管损伤的影响。方法选取2013年3月~2014年3月收治的100例良性胆囊疾病患者,术前磁共振胰胆管造影(magnetic resonance cholangiopancreatography,MRCP)显示:肝外胆管显示清楚者92例(92%);胆囊管显示清楚者85例(85%);左右肝管低位汇合者4例,胆囊管汇入右肝管1例(见图1),副肝管汇入胆囊管者1例。均采取改良的三步法腹腔镜胆囊切除术,即第一步处理胆囊动脉、第二步剥离胆囊、第三步处理胆囊管。术后每2 h观察有无腹痛、发热、黄疸等表现,连续观察3 d,术后第3 d进行肝功能和超声检查,观察是否有急性胆管损伤发生。术后1、3、6个月随访观察有无迟发性胆管损伤。结果术中发现胆囊管变异5例,其中胆囊管极短者1例;胆囊管汇入右肝管者2例;胆囊管汇入右后叶肝管者1例;副肝管汇入胆囊管者1例,100例患者中有96例(96%)成功实施了改良的手术方式,有4例患者(4%)未能实现最后切断胆囊管的操作步骤;平均手术时间(42.74±10.53)min。住院期间未发生出血、胆漏、腹痛、腹腔感染等胆管损伤及其他并发症发生,术后平均住院时间为(3.36±0.72)d。术后1、3、6个月进行的体检、肝功能和腹部超声检查结果显示胆总管轻度扩张16例,无腹痛、黄疸及肝功能异常等迟发性胆管损伤情况发生。结论改良的手术方式能够有效地预防腹腔镜胆囊切除术中胆管损伤的发生,具有重要的临床价值。     

腹腔镜胆囊切除术中经胆囊管胆道造影52例临床分析

目的探讨腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)中选择性经胆囊管胆道造影的应用价值。方法回顾性分析52例LC中经胆囊管胆道造影者的临床资料。结果除1例患者因胆囊管过细,过短及急性胆囊炎致Calot三角粘连、解剖不清而致插管失败外,余51例(98.1%)均插管成功。术中胆道造影发现胆总管结石4例,其中3例术中经纤维胆道镜取石成功,1例因结石嵌顿中转开腹行胆总管切开取石;胆囊管过长或变异3例,在造影片指导下成功完成LC;胆道损伤2例,转开腹行胆总管修补,T管引流术后痊愈出院,术后随访未见明显手术相关并发症。结论 LC术中选择性经胆囊管胆道造影简单易行,能显著降低胆道结石残留和及时发现胆道损伤等严重并发症,值得推广应用。     

腹腔镜胆囊切除中转开腹手术的原因分析

目的分析腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）中转开腹的原因并探讨其防治措施。方法2005年10月-2007年10月共行LC手术405例,中转开腹37例（9.1%）。结果中转开腹的原因：慢性萎缩性胆囊炎5例、解剖变异3例、术中胆管损伤7例、胆囊动脉或肝右动脉损伤出血6例、胆囊三角解剖不清16例,开腹手术均获成功,均痊愈出院。结论熟悉各种解剖变异、规范操作、正确术前评估、熟练的操作技术是减少LC中转开腹手术的关键。     

腹腔镜胆囊切除术胆道损伤后再手术时机和术式选择

目的探讨腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)致胆管损伤的手术时机、手术方式和技巧。方法回顾12例LC后胆管损伤病例,术中发现2例,术后发现10例。胆囊床小胆管损伤1例,胆囊管残端胆漏1例,肝总管胆总管侧壁撕裂、部分剪断9例,肝总管离断1例。结果本组1例术中胆总管侧壁撕裂损伤,经中转开腹行胆总管修补和T管引流而治愈;术后2例出现胆漏,经充分引流后自愈;1例术后2 d行胆总管修补T管引流者术后发生胆管狭窄及胆道炎症,于1年后行胆管空肠Roux-en-Y吻合术后治愈;其余8例均经胆肠吻合术治愈。随访1.5~5年,无胆道狭窄及胆管炎发作。结论手术仍是LC致胆管损伤的首选治疗方法。把握手术时机避免盲目自信,及早选择有经验的专科医生恰当处理是提高治愈率的关键。