腹腔镜胆囊切除术中经胆囊管胆道造影的临床意义

目的 探讨腹腔镜胆囊切除术中行经胆囊管胆道造影对隐匿性胆总管结石及医源性胆管损伤诊断的临床意义.方法 回顾性分析341例腹腔镜胆囊切除术患者的临床资料,其中137例术中行经胆囊管胆道造影,207例未行造影.结果 137例行术中胆道造影者,术中发现胆总管结石11例（8.03％）,胆管损伤1例（0.72％）;术后随访3～6个月发现胆总管残余结石4例（2.92％）,未发现胆管损伤.204例未行术中胆道造影者,术中发现胆总管结石5例（2.45％）,术中未发现胆管损伤;术后随访3～6个月发现胆总管残余结石18例（8.82％）,胆管损伤2例（0.98％）.结论 腹腔镜胆囊切除术中经胆囊管胆道造影操作安全、快速、无创,可提高胆总管结石诊断的敏感度,及时发现胆管损伤,降低胆总管残余结石发生率,避免不必要的胆道探查.     

腹腔镜胆囊切除术中胆道造影100例临床分析

目的:探讨并总结术中胆道造影在腹腔镜胆囊切除术中的应用价值、适应证及操作技巧。方法:回顾分析2011年4月至2015年2月为100例胆囊结石患者行腹腔镜胆囊切除术中施行胆道造影的临床资料,其中急性胆囊炎43例,非急性胆囊炎57例。结果:100例均成功完成腹腔镜胆囊切除术,无一例中转开腹。术中胆道造影均顺利完成。8例患者术中胆道造影发现胆总管结石,行腹腔镜胆囊切除术、胆总管切开取石、T管引流术。手术时间65~140 min,平均(75.6±12.5)min;术中出血量10~120 ml,平均(30.6±11.7)ml;术后住院3~9 d,平均(4.3±0.8)d。术后均未出现出血、胆漏等并发症。结论:在严格掌握胆道造影适应证及腹腔镜操作技术的基础上,腹腔镜胆囊切除术术中行胆道造影是安全、可行的,可提高手术安全性,减少胆管残余结石的发生,值得大力推广。     

腹腔镜胆囊切除术中经胆囊管胆道造影的临床应用

目的探讨腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)术中经胆囊管胆道造影(intraoperative cholangiography by cystic duct,IOC)的临床价值。方法在879例行LC的患者中,对37例术前有剧烈腹痛史、合并胆源性胰腺炎或MRCP可疑胆总管结石及术中胆囊管粗大、胆总管外径≤1.0cm且胆总管明显饱满的病例行IOC。结果成功35例,失败2例;术中发现胆囊管结石4例,胆总管结石3例,两者占IOC总数的18.9%。结论 IOC成功率高,显像清楚,对减少胆总管阴性探查、术后残留胆总管结石及残留胆囊管结石具有重要的临床价值。     

选择性术中胆道造影在腹腔镜胆囊切除术中的应用

腹腔镜胆囊切除术（1aparoscopic cholecystectomy,LC）与传统开腹胆囊切除术（open cholecystectomy,OC）相比,具有患者创伤小、痛苦轻、住院时间短等优点,已被广大患者所接受。术中胆道造影（intraoperative cholangiography,IOC）是常规应用还是选择性应用的争议,     

腹腔镜胆囊切除术中经胆囊管胆道造影的意义

腹腔镜胆囊切除术(laparoscopiccholecystectomy,LC)术中胆道造影(intraoperativecholangiography,IOC)对明确肝外胆道系统在生理和病理状态下的解剖关系和对保证LC手术安全有意义。本研究对施行LC的51例病人术中行经胆囊管插管胆道造影,取得较好效果。对象与方法1.临床资料上海第二医科大学附属仁济医院东院于2002年5月至2002年10月对37例慢性胆囊炎胆囊结石、8例急性胆囊炎胆囊结石、5例胆囊息肉腺瘤变和1例胆源性胰腺炎共51例病人施行了LC,均由一组医师完成。在LC术中均经胆囊管插管常规行胆道造影,其中男20例,女31例;年龄24～78岁…     

术中胆道造影在腹腔镜胆囊切除术中的应用价值

目的 评价术中胆道造影技术在腹腔镜胆囊切除术中的应用价值。方法 腹腔镜胆囊荨除术中经胆囊管插管行胆道造影共１４６６例,１３８２例造影成功,成功率为９４．２７％。结果 术中造影发现胆总管结石９２例,胆管损伤８例,副肝管１例。结论术中造影操作迅速,安全,显影清晰成功率高,能降低胆管损伤发生率;提高腹腔胆囊切除术的质量,值得推广应用。     

选择性胆道造影在腹腔镜胆囊切除术中的应用

目的探讨腹腔镜胆囊切除术（laparoscopy cholecystectomy,LC）中开展选择性的胆道造影技术及其临床应用价值。方法对98例术中胆道造影患者的临床资料进行回顾性分析。结果同期LC 862例,术中胆道造影98例,造影成功90例,成功率为91.8%。术中发现胆管结石7例,胆管损伤1例,胆道解剖异常2例。结论选择性术中胆道造影操作简便安全,成功率高,显影清晰,可有效降低胆管结石的残余率和胆管损伤的发生率,避免不必要的胆道探查,提高LC手术的安全性。     

腹腔镜胆囊切除术中经胆囊管胆道造影的临床意义

随着腹腔镜胆囊切除术(LC)在国内各级医院的逐步普及,在对胆石症的病人进行腹腔镜胆囊切除术的术前或手术中,常常遇到胆囊结石伴有相对胆道探查指征,往往难于确定术式,但又是必须解决的问题.     

腹腔镜术中胆道造影398例分析

目的探讨腹腔镜术中胆道造影对腹腔镜胆囊切除术的应用价值。方法回顾性分析近8年间398例腹腔镜术中胆道造影者的临床资料。结果发现胆总管结石40例，胆囊管内结石3例，胆道畸形54例，胆道损伤6例。均予相应治疗，无死亡。结论腹腔镜术中胆道造影的临床应用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。     

常规/选择性胆道造影在腹腔镜胆囊切除术中的应用研究

目的 探讨腹腔镜胆囊切除术中常规应用和选择性应用胆道造影的效果.方法 常规术中胆道造影组1 520例,选择性术中胆道造影组457例.采用自制造影器或输液针头完成术中造影,比较2组的造影时间、造影成功率、胆总管结石发现率、胆管解剖变异发现率、医源性胆管损伤发生率、中转开腹率以及术后住院时间.结果 2组病例在造影时间、造影成功率、中转开腹率以及术后住院时间方面的差异均无统计学意义(P＞0.05);选择性造影组的胆总管结石发现率、胆管解剖变异发现率以及医源性胆管损伤发生率均高于常规造影组(28.25％比13.43％,10.71％比7.43％,2.05％比1.02％,P＜0.05).结论 在开展腹腔镜胆囊切除术的早期,应采用常规术中胆道造影,以避免医源性胆管损伤的发生和胆总管结石残留.待技术纯熟以后,可以选择性地进行术中胆道造影.     

腹腔镜胆囊切除术中转开腹25例临床分析

目的总结腹腔镜胆囊切除术(laparoscopic cholecystectomy，LC)中转开腹的原因并探讨其防治措施。方法1998年7月-2004年8月共行462例LC，中转开腹21例(14．5％)，回顾性分析其临床特点及治疗效果。结果术中发现右肝管被夹闭1例，胆漏3例，术野不清出血明显17例，予中转开腹进一步处理，均痊愈出院。结论熟悉各种解剖变异、规范精细操作、适时中转开腹是预防LC并发症的关键；胆囊周围粘连严重、解剖困难、出血不易控制、损伤周围脏器、胆囊癌变等情况是中转开腹手术的适应证。     

Efficacy of Cholangiography Under Helical Computed Tomography for Laparoscopic Cholecystectomy

Purpose. Although laparoscopic cholecystectomy (LC) is known to be safe, the optimal imaging technique for examining the common bile duct and cystic duct prior to laparoscopic intervention remains controversial. The objective of this study was to evaluate the efficacy of cholangiography under helical computed tomography (helical CT cholangiography) for LC. Methods. We studied 53 consecutive patients who underwent LC carried out by the same surgeon. The data of 23 of these patients who had undergone LC before the introduction of helical CT were used as the reference standard. Among the 53 patients, 28 were prospectively randomized for preoperative biliary tract evaluation with versus without helical CT cholangiography, into a CT/+ group (n = 13) and a CT/− group (n = 15), respectively. Two patients were excluded from the study preoperatively. Results. There were no significant differences in age or laboratory findings, including liver function tests or the serum amylase level before or after surgery, between the two groups. In the CT/− group, endoscopic retrograde cholangiography-related pancreatitis developed in one patient, and one patient required conversion to open surgery. In contrast, in the CT/+ group, there were no preoperative complications and no patient required conversion to open surgery. The mean operative time was significantly shorter in the CT/+ group than in the CT/− group (P = 0.0137). Conclusion. These findings provide evidence to support the advantages of helical CT cholangiography in relation to operative time, conversion, and procedure-related preoperative complications. Received: May 28, 2001 / Accepted: November 20, 2001     

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。     

Laparoscopic Ultrasonography as a Good Alternative to Intraoperative Cholangiography (IOC) during Laparoscopic Cholecystectomy: Results of Prospective Study

Intraoperative cholangiography (IOC), used routinely or selectively, is the standard method for bile duct imaging during cholecystectomy. Laparoscopic ultrasonography ( LUS) has emerged as a possible, safe and quick alternative. This study examined the evolving use and the performance of these two methods as primary technique for routine bile duct imaging, so as to detect common bile duct stones (CBDS) and to prevent common bile duct injury (CBDI). A prospective database permitted to evaluate the results of the two methods in 968 consecutive cholecystectomies. Nine hundered and twenty five were performed by laparoscopy, 18 (1.9%) by laparotomy and 25 (2.6) necessitated a conversion. The systematic use of the IOC was gradually replaced by a systematic use of the LUS. The success to delineate and evaluate the CBD, the detection of a CBDS, any type of bile duct complication, especially of CBDI, were registered. All the CBDS suspected by LUS were controlled by IOC. The patients were followed during 1 and 6 months. Six hundred and eighty five IOC and 269 LUS were performed. The procedure was technically unsuccessful in 35 IOC (5.1%) (mainly due to difficulty in catheterising the cystic duct) and in 2 LUS (1%) (due to steatosis). Concerning the detection of CBDS, 31 were detected by IOC (4.5%) and 16 by LUS (6%). Five IOC were considered as false positive, 1 as false negative (sensitivity and specificity of 96,9 and 99,2%) and 1 LUS as false positive (sensitivity and specificity of 100 and 99,6%).

Five CBDI were detected in the complete seria: 2 during the dissection before the IOC, 1 thermic injury, 1 late stenosis, 1 lateral stenosis by the cystic clip detected by LUS. However none of these CBDI could have been prevented by IOC.

In our experience, in this prospective study, LUS has been certainly as effective as IOC as a primary imaging technique for bile duct. It permitted to detect CBDS with a high specificity and sensitivity, and CBDS and was not followed by an increase in CBDI.     

腹腔镜胆总管探查一期吻合后术中胆道造影的临床价值

目的探讨在腹腔镜胆总管探查取石（laparoscopic common bile duct exploration,LCBDE）一期吻合后立即经胆囊管插管造影的临床价值。方法 2007年6月～2012年10月92例胆总管结石行腹腔镜胆总管探查一期吻合术,吻合后行胆道造影,术中发现胆道损伤、结石残留及时处理。结果术中造影显示74例吻合满意,吻合口漏6例,胆总管下段穿孔5例,右肝管漏2例,结石残留5例。吻合口漏及右肝管漏镜下补漏成功;胆总管下段穿孔5例开腹修补漏口;5例结石残留开腹直视下取净结石。92例术后均无胆漏、腹腔感染。78例随访1～72个月,平均20.6月,无胆管狭窄,2例术后30个月结石复发,1例术后12个月结石复发,EST取石。结论术中胆道造影在腹腔镜胆总管探查取石一期吻合术中可及时发现胆漏、结石残留,避免术后胆漏,值得临床推广。     

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。     

三孔法腹腔镜胆囊阑尾联合切除68例

目的探讨采用三孔法腹腔镜同时实施胆囊、阑尾联合切除术的可行性。方法对68例急、慢性胆囊炎、胆结石或胆囊息肉合并急、慢性阑尾炎患者实施三孔法腹腔镜胆囊、阑尾联合切除术。结果手术均获成功。平均手术时间70(50~90)m in,平均住院日5(4~7)d。全部病人均恢复正常工作或生活,中位随访7(4~20)个月,无并发症发生。结论在掌握好手术指征及熟练的腹腔镜操作技术的前提下,三孔法腹腔镜胆囊和阑尾联合切除是安全可行的方法。     

老年人腹腔镜胆囊切除术并发症分析

目的探讨老年患者腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）的安全性。方法回顾性分析2004年2月-2007年5月158例行LC手术治疗的老年患者临床资料。结果138例（87.3%）成功施行LC,手术时间平均为（96±23）min,术后平均住院天数为（3.4±1.4）d,20例（12.7%）术中转开腹胆囊切除术。20例（12.7%）患者术后发生并发症,包括肺栓塞1例（0.6%）,胆漏2例（1.3%）,脐疝3例（1.9%）,胆总管结石残留3例（1.9%）,切口感染3例（1.9%）,切口出血6例（3.8%）,腹膜炎2例（1.3%）。术后30 d内无一例死亡。结论重视术前评估及术中Calot三角处理,规范操作以及掌握好中转开腹原则是老年患者LC术安全进行的可靠保障。     

Bile Duct Injury during Laparoscopic Cholecystectomy: Risk Factors,Mechanisms, Type,Severity and Immediate Detection

34-year-old male with history of recurrent atrial fibrillation (AF) and mitral stenosis, status post radio-frequency ablation (RFA) and prosthetic mitral valve replacement two years earlier was admitted with prosthetic valve thrombosis for redo mitral valve surgery. During the surgery, a 2 χ 1.5 χ 1 cm mass was identified on the interatrial septum, attached to the edge of tricuspid valve’s septal leaflet by a stalk. The mass was excised and histological evaluation revealed myxoma. It is accepted that myxomas can develop after cardiac trauma. It is known that RFA for AF increases the risk of thrombus or endocarditis in the atrium. Herein, we report a myxoma case where we think the heat energy caused by RFA might have triggered the development of the tumor.