腹腔镜在6月龄以内新生儿和婴儿疾病诊断和治疗中的应用(附297例报告)

目的 探讨腹腔镜技术在新生儿和小婴儿疾病诊断和治疗中的安全性及可行性. 方法 2001年1月～2007年5月,我们对297例新生儿及小婴儿进行腹腔镜手术治疗.年龄生后2小时～6个月,其中先天性肥厚性幽门狭窄80例,梗阻性黄疸67例,腹股沟斜疝35例,胆道闭锁31例,中高位肛门闭锁21例,胆汁黏稠21例,先天性膈疝7例,空肠闭锁7例,胆总管囊肿6例,先天性巨结肠5例,十二指肠膜式狭窄5例,肾积水3例,食管裂孔疝2例,食管闭锁2例,肠旋转不良2例,小肠梗阻1例,肠套叠1例,先天性肌性斜颈1例. 结果 诊断性手术胆道造影术67例;操作简单的中小手术如幽门环肌切开术80例,疝囊高位结扎术35例,胆道冲洗术21例,十二指肠膜式狭窄手术5例,肠旋转不良Ladd手术2例,肠套叠复位术1例,肠粘连松解术1例,胸锁乳突肌松解术1例;复杂性大手术如肝门空肠吻合术31例,肛门成形术21例,膈疝修补术7例,肠闭锁肠切除吻合术7例,肝管空肠吻合术6例,长段型巨结肠根治术5例,肾盂成形术3例,食管闭锁2例,食管裂孔疝胃底折叠术2例.无术中大出血、无术中及术后需要输血者、意外损伤及围手术期死亡病例.腹腔镜下完成手术294例,3例胆道闭锁因术中肝门渗血中转开腹手术.术后随访2个月～6年,无明显远近期并发症发生. 结论 腹腔镜技术是诊断、治疗新生儿和小婴儿疾病的安全、可靠的方法,具有创伤小,恢复快,美容效果满意等优势.     

腹腔镜用于婴幼儿梗阻性黄疸诊断和治疗的评价

目的 探讨腹腔镜在婴幼儿梗阻性黄疸诊断和治疗中的价值。方法 对52例婴幼儿梗阻性黄疸采用腹腔镜协助诊断和治疗。结果 2例因大量腹水而中转开腹，余50例腹腔镜下行胆道造影明确诊断，其中胆道闭锁33例，胆道发育不良10例，胆汁淤积7例。中转开腹行肝门—肠吻合术43例，肝活检38例，胆道置管行胆道冲洗9例。结论 腹腔镜诊断和治疗婴幼儿梗阻性黄疸具有准确，可靠的优点。对胆汁淤积的患儿，可免除开腹手术。     

腹腔镜胆总管囊肿根治术的手术体会及技术改进

目的 总结腹腔镜胆总管囊肿切除、肝管空肠Roux-Y吻合术的临床经验,并探讨其手术技巧和技术改进.方法 2010年11月-2012年11月,共实施腹腔镜胆总管囊肿根治术31例.采用4孔法,先游离胆囊,行胆道造影,然后扩大脐部切口提出空肠,完成Roux-Y吻合,还纳肠管后再切除囊肿,行胆肠吻合术.结果 31例患者,2例中转开腹,29例完成腹腔镜下胆总管囊肿根治术,手术时间为200 ～ 460 min,平均260 min;术后早期并发症3例(9.7％),其中胆瘘1例;术后腹壁切口出血1例;Roux-Y胆袢扭转1例.术后患儿均获得随访,随访时间为3～ 27个月,全部患儿肝功能正常,超声检查无结石形成,未见胆管狭窄及扩张.结论 腹腔镜胆总管囊肿根治术安全可靠,效果满意.     

婴儿胆道扩张症伴胆道发育不良的手术治疗

目的 探讨巨大胆总管囊肿伴胆道发育不良症患儿的诊断和手术难点.方法 回顾性分析胆道扩张症患儿278例,其中3例伴有肝外巨大囊肿的胆道发育不良症患儿.本组患儿术中都进行胆道造影检查,了解肝内、外胆管通畅情况以及肝内胆管扩张情况;术中行肝脏活检,行囊肿切除术,术中放置肝总管支架管,并行肝总管-空肠Roux-en-Y吻合手术. 结果 3例患儿手术年龄在1～2个月之间,术中造影显示囊肿较巨大,左、右肝管发育较细且与肝内相通,有黄色胆汁流出.切开囊肿时有1例损伤肝总管,行肝总管修补手术,并行肝总管部位囊肿成型术,再行肝门-空肠吻合术.3例患儿术后无吻合口狭窄和结石形成;肝活检病理证实有通畅胆管,但胆管数量减少,未见类似胆道闭锁的胆管增生以及胆栓形成.术后随访1～5年,未见黄疸发生,超声显示无肝内胆管扩张.结论 术中胆道造影检查非常必要,如遇囊肿巨大,左、右肝管较细,切开囊肿时应小心,切口位置选择在胆囊管水平以下,勿损伤肝管,造成吻合困难,吻合时放置支架管对于早期胆汁引流意义重大.     

腹腔镜肝门肠吻合术治疗胆道闭锁的探讨(12例报告)

目的:探讨经腹腔镜辅助行肝门解剖和肝门肠吻合术治疗先天性胆道闭锁的临床效果。方法:先天性胆道闭锁患儿12例,29~87d11例,5.5个月1例。2例为肝总管闭锁(Ⅱ型),肝门部有直径1.2~2.5cm囊肿与肝内胆管相通;10例为肝门部胆管闭锁(Ⅲ型)。于脐部纵切口置入10mmTrocar,然后分别于右上腹、右中腹和左上腹置入3个5mmTrocar。术中胆道造影,确诊为胆道闭锁,暴露肝门;切除胆囊,游离切除肝门纤维块,空肠行Roux-en-Y吻合术保留肝支30~35cm,然后将肠管送回腹腔,将空肠肝支经结肠后拉至肝门下;用5-0可吸收缝线将空肠与肝门端侧连续吻合。结果:本组12例患儿中1例因肝门渗血中转开腹手术;另11例均在腹腔镜辅助下完成手术,手术时间平均为3.5h(3.1~4.6h),出血量约10ml,没有需在术中和术后输血者,全组患儿无手术后肠粘连梗阻和腹腔感染。结论:经腹腔镜行肝门肠吻合术治疗先天性胆道闭锁安全可靠,具有暴露肝门清晰、肝门纤维块分离和切除准确、对患儿打击小等优点。     

腹腔镜辅助胆道造影在幼婴延迟性黄疸诊断中的价值

目的探讨腹腔镜辅助胆道造影在幼婴延迟性黄疸诊断中的价值。方法首先脐部置镜观察胆囊及肝脏情况,如果胆囊大小正常或基本正常,通过右肋缘下trocar孔拖出胆囊底部,部分患儿需游离胆囊系膜。切开胆囊,插管行胆道造影。如果胆囊呈纤维闭锁状态,不能拖出腹腔外,中转开腹。切开胆囊插管失败,放弃造影。结果12例患儿直接从拖出胆囊行胆道造影显示婴儿肝炎综合征或胆汁淤积8例;2例显示为胆管发育不良;2例为肝内胆管闭锁。5例从肝脏游离胆囊系膜后拖出造影,2例显示为胆管发育不良,3例提示胆道闭锁。其余21例患儿胆囊呈条索状,不同程度肝硬化,放弃胆道造影,诊断为胆道闭锁。所有胆道闭锁患儿均行Kasai手术。结论腹腔镜探查、胆道造影是诊断胆道闭锁、鉴别幼婴延迟性黄疸简便、准确、安全的方法,能够显示整个胆树的解剖结构,避免过大或不必要的创伤。     

腹腔镜辅助与开腹肝门空肠吻合手术治疗Ⅲ型胆道闭锁的疗效分析

目的 比较腹腔镜辅助与开腹肝门空肠吻合术治疗Ⅲ型胆道闭锁的临床效果.方法 2003年5月～2005年9月,手术治疗Ⅲ型胆道闭锁71例.腹腔镜辅助肝门空肠吻合术26例,排除3例因肝门部渗血而中转开腹病例;同期开腹肝门空肠吻合术42例.比较2组间的近期胆汁引流效果、远期胆管炎发生率和大于18个月生存率. 结果 与开腹组相比,腹腔镜组手术时间长[(189.0±36.2)min vs(157.0±30.4)min,t=3.919,P=0.000)];出血量少[(15.4±5.0)ml vs(33.8±19.4)ml,t=-4.727,P=0.000)].术后1～4周胆汁引流率(术后4周直接胆红素降至正常水平或较术前下降超过60%)2组相近[65.4%(17/26)vs 69.0%(29/42),χ2=0.098,P=0.754];随访期间胆管炎发作>3次发生率相近[15.4%(4/26)vs 33.3%(14/42),χ2=2.658,P=0.103];>18个月生存率相近[38.5%(10/26)vs 52.4%(22/42),χ2=1.249,P=0.264].腹腔镜组1例术后脐部切口疝.2组均无术中和术后输血者,无粘连性肠梗阻和腹腔感染. 结论 传统开腹肝门空肠吻合术治疗Ⅲ型胆道闭锁远期疗效与腹腔镜辅助肝门空肠吻合术差异无显著性.     

腹腔镜治疗小儿胆道穿孔12例临床体会

目的:总结腹腔镜手术治疗小儿胆道穿孔的临床体会。方法:2008年12月至2015年12月收治12例胆道穿孔患儿,均经腹腔镜探查证实为胆道穿孔,根据病情分别行胆总管囊肿T管引流+腹腔引流、胆囊造瘘术+腹腔引流、单纯腹腔引流。结果:12例患儿均成功完成手术,术后未出现胆道出血、胆漏等并发症。胆汁引流及腹腔引流24~72 h后,临床症状缓解,腹痛显著减轻,体温降至正常,黄疸逐步消退。8例胆总管囊肿穿孔患者术后6个月行二期胆总管囊肿切除、肝总管空肠Roux-Y吻合术,其中5例在腹腔镜下完成二期手术,3例因胆总管周围粘连重、分离困难中转开腹。结论:腹腔镜用于小儿自发性胆道穿孔的诊断与治疗避免了盲目开腹探查的缺点,创伤小,手术视野广,对腹腔及肠管干扰小,手术时间短,胆总管囊肿穿孔不影响二次腹腔镜手术。     

Laparoscopic resection of cyst and Roux-Y hepaticojejunostomy in chileren with choledochal cyst

目的 总结腹腔镜下胆总管囊肿根治手术的经验.方法 从2010年7月至2011年10月,对我院22例胆总管囊肿患儿行腹腔镜下囊肿切除、肝总管空肠Roux-Y吻合术.结果 3例因囊壁炎症重而中转开腹,其余均完成腹腔镜手术,平均手术时间4.6小时(3.5～6.5小时).术后3例出现胆瘘,经通畅引流后愈合.术后美容效果明显.随访至今未出现胆道狭窄、胆道感染等并发症.结论 腹腔镜下根治小儿胆总管囊肿是安全可靠的.     

胆总管囊肿伴肝总管狭窄患儿的腹腔镜手术治疗

目的探讨腹腔镜手术治疗胆总管囊肿伴有肝总管狭窄患儿的治疗方法。方法自2007年1月至2009年12月，共收治胆总管囊肿患儿41例，其中7例伴有肝总管狭窄的患儿均在腹腔镜下完成手术。采用四孔Trocars技术，先在腹腔镜下游离胆囊并将其提出腹壁外，行38％泛影葡胺造影，判断胆总管囊肿及肝总管的情况；电凝钩或超声刀游离切除囊肿；于脐孔处提出空肠行端侧吻合术；腹腔镜探查近端肝总管情况，将狭窄肝总管前壁向近端游离、切开、成形，并探查肝内胆管；行镜下胆肠端侧吻合术。结果7例胆总管囊肿伴有肝总管狭窄的患儿均在腹腔镜下完成手术，术中造影及腔镜探查证实囊肿近端肝总管狭窄，直径1～2mm，长度2mm左右，切开狭窄肝总管前壁至宽敞部，3例伴有肝总管结石，1例伴有蛋白栓，均游离近端肝总管行肝肠吻合。术后黄染、腹疼等症状消失，随访6个月至2年均无胆系感染或胆道梗阻发生。结论胆总管囊肿伴有肝总管狭窄的患儿在腹腔镜下行狭窄肝总管切开成形、胆肠吻合术，比开放性手术更容易操作，预后好，能够预防胆道梗阻及胆管炎的发生。     

Surgical jaundice in infancy.

The surgery of congenital malformations of the biliary system has undergone a revolutionary change during the past decade. Although Kasai's hepatic portoenterostomy operation for biliary atresia is the most dramatic example, radical departures from conventional surgical treatment also have been advocated for choledochal cyst, Caroli's disease, congenital perforation of the bile ducts and biliary hypoplasia. This communication describes the lesions responsible for obstructive jaundice in the early months of life, briefly reviews standard treatment and consolidates the available information about the new operative procedures currently proposed for congenital anomalies of the biliary tract.     

先天性胆总管囊肿再次手术的原因分析及治疗

目的 探讨先天性胆总管囊肿再次手术的原因及治疗方法.方法 对41例先天性胆总管囊肿再次手术患者的临床资料进行总结分析.结果 按先天性胆总管囊肿Todani分型,41例中Ⅰ型32例,Ⅱ型1例,Ⅳ型3例,Ⅴ型5例(其中1例呈弥漫性左右肝分布).既往有1次胆道手术史者30例,2次者8例,3次者3例.41例中合并有胆管结石40例,胆道感染33例,肝门部胆管狭窄7例,原胆肠吻合口狭窄6例,囊肿癌变5例.本次行切除肝外胆管囊肿、肝管空肠Boux-en-Y吻合术者32例,其中2例囊肿癌变者同时行肝十二指肠韧带骨骼化和区域淋巴结清扫术;行肝叶切除联合胆总管囊肿切除、肝管空肠Roux-en-Y吻合术者8例;行胆肠吻合口狭窄切开成形、胆肠内引流重建术1例.41例术后均获随访,随访时间3个月至10年,平均53.7±32.1个月,随访期内发生胆道感染4例,无吻合口狭窄或结石复发等并发症发生.结论 胆总管囊肿术式选择不当及诊断失误导致的多种并发症是导致再手术的主要原因,肝内外胆管囊肿切除、肝管空肠Roux-en-Y吻合术可取得较为满意的疗效.     

Laparoscopic resection of type I choledochal cyst

Type I choledochal cyst is a rare saccular or fusiform congenital dilatation of the extrahepatic biliary tract. It is usually treated by laparotomy at which the cyst is completely excised and a Roux-en-Y hepaticojejunostomy is performed to establish biliary enteric drainage. We report the laparoscopic excision and hepaticoduodenostomy of type I choledochal cyst in two girls aged 1 and 3 years. The entire procedure was performed laparoscopically using needlescopic instruments. A 7-mm telescope port was inserted at the umbilicus, a 3-mm port in the right upper quadrant, and a 6-mm port in left upper quadrant. An additional 3-mm fan-shaped liver retractor was passed through the abdominal wall without a trocar. The gallbladder and choledochal cyst was dissected and removed en bloc. The lower end of the common bile duct was closed with 5-0 polydioxanone. The duodenum was anastomosed to the common hepatic duct below the confluence of the right and left hepatic ducts. There were no intraoperative complications, and the children were asymptomatic with no episodes of cholangitis at 6 months follow-up. Pediatric surgeons trained in advanced laparoscopic techniques including intracorporeal suturing can perform laparoscopic repair of choledochal cyst safely.     

Initial experience with complex laparoscopic biliary surgery in children: biliary atresia and choledochal cyst

Background

Laparoscopic approaches are possible for many pediatric surgical diseases, including complex biliary disorders. The authors describe their early experience with laparoscopic procedures for biliary atresia and choledochal cysts.

Methods

A retrospective review was performed with Institutional Review Board (IRB) approval of children undergoing laparoscopic Kasai portoenterostomy (n = 2) or laparoscopic excision of a choledochal cyst with Roux-en-y biliary reconstruction (n = 3). The authors report the operative technique for these procedures and present their initial results.

Results

All procedures were performed with 4 to 5 trocars using 3- and 5-mm ports. Excision of the fibrous biliary remnant (biliary atresia) or of the cyst (choledochal cysts) was performed laparoscopically in all cases. The Roux-en-y limb was created through a 1-cm extension of the umbilical port site. Laparoscopic biliary reconstruction was performed successfully in 4 of 5 patients. In one child, the proximal extent of the choledochal cyst was at the bifurcation of the hepatic duct, and the biliary reconstruction was performed via an open incision with separate anastomoses of the right and left ducts. The gallbladder was used as a handle for retraction of the liver for portal visualization, as in a cholecystectomy, and was resected at the end of the procedure. All children with choledochal cysts have normal bilirubin values. One of 2 children who underwent laparoscopic Kasai has a normal postoperative bilirubin level, whereas the other child did not drain bile and underwent a successful liver transplantation. Mean length of surgery was 338 minutes; mean length of stay was 5.5 days. There were no significant postoperative complications. Cosmesis was excellent in all cases.

Conclusions

Laparoscopic approaches for children with biliary atresia and choledochal cysts are possible. Excellent visualization of the portal structures can be achieved laparoscopically with adequate retraction of the liver. Further follow-up is needed to determine broader application.     

Surgery of coexisting biliary malformations in choledochal cyst

Five of 13 infants and children with a choledochal cyst had coexisting biliary malformations. The specific lesions were main hepatic duct cyst (2), common hepatic duct stenosis (1), left hepatic duct stenosis (1), and Caroli's disease (1). The malformations were corrected or partially corrected at the time of operative resection of the cyst. The lateral portion of either or both of the major hepatic ducts was incised to the liver hilus thereby dividing areas of stenosis or laying open cystic malformations. Biliary reconstruction was by Roux-en-Y jejunostomy to the fileted common hepatic bile duct. The opportunity to correct coexisting biliary malformations is another advantage of total excision of choledochal cysts.     

Spontaneous perforation of right hepatic duct in a child with choledochal cyst

A 5-year-old girl with choledochal cyst (Alonso Lej, type I) and spontaneous perforation of the right hepatic duct during an attack of acute pancreatitis was treated by two-stage surgery. Biliary panperitonitis was diagnosed by abdominal paracentesis, bilirubin and amylase levels in the collected fluid being 41.3 mg/dl and 1812 Somogyi U, respectively. The initial surgery involved simple peritoneal drainage and decompression of the bile duct, followed by removal of a choledochal cyst and the common hepatic bile duct, including the biliary stricture of the left hepatic duct, and biliary reconstruction 5 months later. Cholangiogram after the initial surgery demonstrated pancreaticobiliary maljunction and stricture in the left hepatic duct and the common hepatic duct. Regurgitation of pancreatic juice into the bile duct was shown by the extremely high amylase level (90100 Somogyi U) in the bile drained through a T-tube. The patient is currently well, with normal liver and pancreatic function tests. The experience in this patient is significant in that it should be known that spontaneous perforation of the bile duct may occur at the right hepatic duct in choledochal cyst, causing biliary peritonitis.     

Congenital cystic dilatation of the intrahepatic bile ducts (Caroli's disease): report of a case and review of the literature.

A case of congenital cystic dilatation of the intrahepatic bile ducts (Caroli's disease) followed for more than 7 years is reported. This patient presented also with congenital hepatic fibrosis, gallstones, and biliary hypersecretion of more than 3,000 ml in 24 hours. An analysis of the literature relating to Caroli's disease disclosed 46 well-documented cases of both hepatic histopathology and biliary tree studies. Six cases (13%) were found to be isolated forms of intrahepatic cystic dilatations; 16 (34.7%) were associated with congenital hepatic fibrosis; 10 (21.7%) presented with either a choledochal cyst or nonobstructive extrahepatic biliary tree dilatation; and in 14 cases (30%) the three anomalies were found together in the same patient. After these findings, we think that congenital hepatic fibrosis, congenital cystic dilatations of the intrahepatic bile ducts (Caroli's disease), choledochal cyst and other nonobstructive dilatations of the extrahepatic biliary tree are possibly the same congenital disease with different levels of involvement.     

先天性胆总管囊肿23例诊治体会

目的探讨先天性胆总管囊肿的诊断和治疗方法。方法对23例先天性胆总管囊肿患者行胆总管囊肿切除,肝总管空肠Roux-en-Y端侧吻合术,回顾性分析患者的临床资料。结果 2例出现胆漏,经引流8～12 d后好转,1例反复胆道感染,经抗菌素治疗症状得到控制,余患者恢复良好。结论胆总管囊肿切除,肝总管空肠Roux-en-Y端侧吻合术是治疗先天性胆总管囊肿的较好术式。