腹腔镜复杂胆囊切除术中预防医源性胆道损伤的临床体会

目的:总结腹腔镜复杂胆囊切除的术式选择及预防医源性胆道损伤的临床经验。方法:回顾分析2020年9月至2021年10月为94例患者行腹腔镜复杂胆囊切除术的临床资料,并总结其手术方法与术中处理技巧。患者19～84岁,平均(54.1±14.0)岁,急性化脓性胆囊炎24例,胆囊萎缩17例,充满型胆囊结石12例,24例有腹部手术史,坏疽性胆囊炎6例,胆囊穿孔5例,Mirizzi综合征2例,胆道解剖结构异常1例,冰冻样Calot三角40例。结果:术中发现患者Calot三角均粘连严重。90例患者成功完成腹腔镜手术,4例中转开腹,无其他术中副损伤发生。手术时间15～210 min,平均(55.1±30.5)min;术中出血量0～2 100 mL,中位数20(10,30)mL;住院2～24 d,平均(6.1±3.3)d。术后均无胆漏、医源性胆道损伤等并发症发生。结论:术者具备丰富经验、术中正确处理可更好地预防医源性胆道损伤的发生。     

腹腔镜胆囊切除术胆道损伤的预防

目的探讨如何预防腹腔镜胆囊切除术中胆道损伤。方法回顾分析1999年10月．2004年10月502例腹腔镜胆囊切除术的临床资料。结果18例因胆囊Calot’s三角严重粘连、胆囊严重萎缩或既往有上腹部手术史,致使局部紧密粘连者中转开腹,502例中1例胆道损伤。术后2-5天（平均3天）出院。结论腹腔镜胆囊切除术应严格选择病例,仔细处理Calot’s三角,使用超声刀分离,适时中转开腹手术是预防胆管损伤的重要措施。     

腹腔镜胆囊切除术预防胆道损伤的体会

目的　探讨腹腔镜胆囊切除术胆道损伤的防治方法。方法　回顾性总结 32 0例腹腔镜胆囊切除术的经验。结合文献复习分析胆道损伤可能发生的原因以及其预防和处理。结果　 32 0例腹腔镜胆囊切除术无 1例胆道损伤。结论　腹腔镜胆囊切除术胆道损伤的预防是关键。损伤的处理应根据发生的时间、部位及程度等选择不同的方法     

腹腔镜复杂胆囊切除术时预防胆道损伤的经验

目的总结有效预防腹腔镜下复杂胆囊切除术中胆道损伤的经验。方法回顾我院近十年来所开展的512例腹腔镜下复杂胆囊切除术，对其经验进行总结分析。结果腹腔镜胆囊切除术(lapamscopic cholecystectomy，LC)成功率为95．9％(491／512)，中转开腹率为4．1％(21／512)，1例LC术后发生胆囊床迷走胆管漏，经保守治疗治愈。均未发生胆道损伤或手术死亡。随访310例，时间6～24月，无一例发生胆管狭窄，继发胰腺炎4例保守治疗痊愈。结论扎实的微创外科技能、术前对手术难度的充分评估、术中显露清楚、操作细致以及果断中转开腹，是避免LC手术时胆道损伤的关键。     

腹腔镜胆囊切除术初期预防胆道损伤体会

胆道损伤是腹腔镜胆囊切除术（ＬＣ）最严重的并发症，在ＬＣ初期更易发生，如何预防ＬＣ初期严重的胆道损伤是亟待解决的问题。我们于１９９６年５月～１２月开展ＬＣ１３０例，未发生胆道损伤，现总结如下。临床资料一般资料：男２５例，女１０５例，年龄１２～８４岁。...     

腹腔镜下胆囊切除术中胆道损伤的预防及应对措施

目的探讨腹腔镜下胆囊切除术中胆道损伤的预防及应对措施。方法分析笔者所在医院收治的腹腔镜下胆囊切除术中胆道损伤患者的临床资料,依据修复方式不同分为观察组与对照组。结果胆管损伤原因主要为术者技术原因引起的损伤、胆囊管或胆管变异、Calot三角解剖不清、胆囊管结石嵌顿、胆总管粘连。观察组术中出血量、手术时间、术后进食时间、住院时间均明显低于对照组,同时观察组胆道损伤修复成功率和中转开腹率均明显优于对照组,差异均有统计学意义（P〈0.05）。结论通过对胆道生理结构异常、炎症浸润粘连情况进行分析,对减少胆道损伤,提高临床疗效具有重要的意义。     

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胆道损伤的治疗与预防

腹腔镜胆囊切除术中胆道损伤的治疗与预防龚建平，王敖川（第三军医大学西南医院肝胆外科重庆６３００３８）胆道损伤是胆囊切除术中常见并发症。轻者给病人增加痛苦，重者可造成病人终身残废乃至死亡。腹腔镜胆囊切除术（ＬＣ）目前已成为一项成熟的手术方式而被广泛采用...     

腹腔镜胆囊切除术中胆道损伤的预防

腹腔镜胆囊切除术(Laparoscopic Cholecystectomy,LC)具有创伤小、恢复快、切口美观等微创优势,已取代开腹胆囊切除术(OC)成为标准术式。但是,文献报道医源性胆管损伤的发生率也由开腹时代的0.1%～0.2%上升为腹腔镜时代0.4%～0.6%。多数胆道损伤都发生在腔镜外科医生的学习曲线内,曾经希望胆管损伤的发生率在外科     

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。     

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.     

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.     

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。     

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.     

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.     

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。