腹腔镜胆囊切除术胆管损伤及术后胆漏的临床分析

目的 分析腹腔镜胆囊切除术后胆漏及胆管损伤的原因、治疗方法及预后。方法 总结1999年1月～2005年7月7例腹腔镜术后胆漏及胆管损伤的患者，进行回顾性分析。结果 7例患者中2例迷走胆管漏，1例经腹腔引流后治愈，1例经B超引导穿刺引流后治愈；胆囊管残端漏1例，再次手术缝扎，胆总管探查取石放置T型管引流后治愈，肝总管损伤漏2例，1例用3-0可吸收线间断缝合，放置腹腔引流治愈，1例剖腹手术修补漏口，放置T型管支撑6个月；胆总管横断2例剖腹行胆总管端端吻合放置T管支撑6-7个月。术后随访1～3年，均恢复良好。结论 腹腔镜胆囊切除术后的胆漏及胆管损伤，应及时发现，正确处理。     

腹腔镜胆囊切除术细小胆管损伤的诊断与处理（附１３例报告）

目的 总结腹腔镜胆囊切除术（ＬＣ）时细小胆管损伤的诊断处理体会。方法 统计分析１２５０例ＬＣ手术中１３例细小胆管损伤的情况。６例于术中发现漏胆点,予钛夹钳夹;４例未找到漏胆点,予引流;３例术后出现胆汗性腹膜炎,其中１例剖腹探查并缝扎漏胆法处,另２例经腹壁戳孔放多孔尿管引流。结果 １３例均获痊愈,术后出现胆法性腹膜炎者经治疗也未产生严重后果。结论 ＬＣ时细小胆管损伤难以避免。术中发现并处理效果最好。术后发现应行开腹手术或充分引流,对漏胆量少者经腹壁戳孔放置引流是可取的方法。     

腹腔镜胆囊切除术后胆道损伤的处理策略

目的 探讨腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）术后胆道损伤时合理的处理策略.方法 回顾性分析11年间我院处理的17例LC手术后胆道损伤的临床资料,其中胆囊床小胆管损伤4例,采用缝扎或内镜下胆道引流;主要胆管部分损伤8例,采用单纯修补、内镜下引流、放置支架或胆管空肠Roux-en-Y吻合;胆总管或肝总管完全横断4例,予对端吻合或胆肠吻合;左右肝管横断1例,二期整形后行胆肠吻合.胆道再狭窄患者予内镜下扩张并置入支架,效果不佳者行胆肠吻合.结果 所有患者均无重大并发症发生,疗效满意.结论 LC手术胆道损伤重在预防,一旦损伤,需由有经验的胆道专科医生依据损伤情况选择干预方式,方能达到最好疗效.     

Treatment of iatrogenic common bile duct injury during laparoscopic cholecystectomy through the laparoscopic insertion of a T-tube stent

Summary Iatrogenic injury to the common bile duct during laparoscopic cholecystectomy has previously necessitated an immediate laparotomy to alleviate bile leakage. In the course of 171 laparoscopic cholecystectomies performed at our hospital, intraoperative common bile duct injuries occurred in 2 patients. Each case was successfully treated using a laparoscopically placed T-tube, thus avoiding the need for a laparotomy. This novel intraoperative procedure successfully treated common bile duct injuries without resulting in postoperative complications.     

Management of major bile duct injuries after laparoscopic cholecystectomy

Background: The aim of this study was to analyze the presentation, characteristics, related investigation, and treatment results of major bile duct injuries (MBDI) after laparoscopic cholecystectomy (LC).Methods: We performed a retrospective analysis of 27 patients who were treated between January 1995 and December 2002 for MBDI after LC at a single unit in a tertiary center. Major bile duct injury was defined according to the Strasberg classification. All patients underwent magnetic resonance cholangiography (MRC), percutaneous transhepatic cholangiography (PTC), or endoscopic retrograde cholangiopancreatography (ERCP) to delineate the biliary anatomy and assess the level of injury. On the basis of the cholangiographic findings, all patients underwent Roux-en-Y hepaticojejunostomy after a waiting period of 8-12 weeks.Results: A total of 29 hepaticojejunostomies were performed in 27 patients. Seventeen patients (63%) presented with biliary fistula and ascites; 10 (27%) presented with obstructive jaundice. In 14 patients (52%) the MBDI was identified during the LC. Twenty patients (74%) had undergone one or more procedure before referral. Eight patients (30%) had E1, five patients (18.5%) had E2, nine patients (33%) had E3, and five pattients (18.5%) had E4 injury. Two patients had early anastomotic stricture, for which redo hepaticojejunostomy with access loop was performed.Conclusions: Major bile duct injury after LC commonly presents with biliary fistula and ascites. High-injuries are common after LC. Hepaticojejunostomy repair yields excellent results in these cases.Presented at the First European Endoscopic Surgery Week, at the annual meeting of the European Association for Endoscopic Surgery (EAES), Glasgow, Scotland 15–18 June 2003     

Bile duct complications after laparoscopic cholecystectomy

Summary A retrospective review and analysis of patients referred to the Division of Gastroenterology and the Section of Gastrointestinal Surgery with common bile duct complications after laparoscopic cholecystectomy was undertaken in order to identify injury patterns, management, and outcome. Sixteen patients were identified over a 20-month period. Twelve patients had major common bile duct injuries and four had minor injuries (cystic duct leaks). Seventy-one percent of injuries occurred with surgeons who had done more than 13 laparoscopic cholecystectomies. Eighty-three percent of patients who had major ductal injury did not have a cholangiogram prior to the injury. Sixteen percent of patients with major common bile duct injuries had findings of acute cholecystitis and 58% of these major injuries were easy gallbladders. One-third of major injuries were recognized at operation. Two-thirds of immediate repairs failed. All cystic duct leaks were managed nonoperatively.It appears that bile duct complications after laparoscopic cholecystectomy are more common in the community than is reported. Bile duct complications occur with surgeons who are experienced and inexperienced with laparoscopic cholecystectomy. Common bile duct injuries, unrecognized at laparoscopic cholecystectomy in the majority of cases, usually occur with easy gallbladders. Operative cholangiography is not utilized in the majority of common bile duct injuries. When immediate repair of common bile duct injuries is undertaken, the majority are unsuccessful. Endoscopic retrograde cholangiopancreatography (ERCP) is invaluable in the diagnosis and management of bile duct complications. Cystic duct leaks may be managed successfully with endoscopic stents.Presented at the annual SAGES meeting, April 10–12, 1992, Washington, D.C.     

应用“胆总管窗”行腹腔镜胆囊切除术

目的探讨“胆总管窗”在腹腔镜胆囊切除术中的应用价值。方法选择2009年6月1日至2009年10月31日期间行腹腔镜胆囊切除的患者55例,以“胆总管窗”为标志行腹腔镜胆囊切除术,观察术中“胆总管窗”以及肝总管和胆总管在肝门与“胆总管窗”连线的出现率,分析肝总管、胆总管、胆囊管与肝门至“胆总管窗”连线的关系。结果“胆总管窗”的出现率为92．7％（51／55）,98％肝总管和胆总管位于肝门与“胆总管窗”的连线上,并能被显露,胆囊管位于此线右侧。在胆囊急性炎症发作时,肝十二指肠韧带炎症水肿明显,大多数患者仍能观察到“胆总管窗”。结论运用“胆总管窗”作为解剖标志,在肝门与“胆总管窗”的连线上显露肝总管和胆总管,能够很好地显示肝总管、胆总管、胆囊管之间的关系。以“胆总管窗”为标记进行操作,有助于降低腹腔镜胆囊切除术中胆管损伤的发生率。     

腹腔镜胆囊切除术致胆管损伤的诊治体会(附22例报告)

目的 探讨腹腔镜胆囊切除术(LC)中胆管损伤的预防和处理。方法 回顾性分析LC胆管损伤22例的特点、诊断、治疗及效果。结果 本组22例均行胆管空肠Roux—en—Y吻合，其中8例行肝门部胆管成形术，3例行中肝叶切除。22例于术后1年、3年随访未出现胆管狭窄、黄疽复发及胆管炎症状。结论 预防胆管损伤是关键，其处理应根据发现时间、部位、类型等选择不同的方法。     

Major bile duct injuries after laparoscopic cholecystectomy: A tertiary center experience

Bile duct injury is a severe and potentially life-threatening complication of laparoscopic cholecystectomy. Several series have described a 0.5% to 1.4% incidence of bile duct injuries during laparoscopic cholecystectomy. The aim of this study was to report on an institutional experience with the management of complex bile duct injuries and outcome after surgical repair. Data were collected prospectively from 40 patients with bile duct injuries referred for surgical treatment to our center between April {dy1998} and December 2003. Prior to referral, 35 patients (87.5%) underwent attempts at surgical reconstruction at the primary hospital. In77.5%of the patients, complex typeE1or typeE2BDIwas found. Concomitant with bile duct injury, seven patients had vascular injuries. Roux-en-Y hepaticojejunostomy was carried out in 33 patients. In two patients, Roux-en-Y hepaticojejunostomy and vascular reconstruction were necessary. Five patients, one with primary nondiagnosed Klatskin tumor, required right hepatectomy. Two patients, both with bile duct injuries and vascular damage, died postoperatively. Because of progressive liver insufficiency, one of them was listed for high-urgency liver transplantation but died prior to intervention. At the median follow-up of 589 days, 82.5% of the patients are in excellent general condition. Seven patients have signs of chronic cholangitis. Major bile duct injuries remain a significant cause of morbidity and even death after laparoscopic cholecystectomy. Because they present a considerable surgical challenge, early referral to an experienced hepatobiliary center is recommended.     

Right hepatic lobectomy for bile duct injury associated with major vascular occlusion after laparoscopic cholecystectomy

A 57-year-old woman underwent laparoscopic cholecystectomy (LC) for cholelithiasis. Continuous bile leak was observed beginning on the first postoperative day. Postoperative endoscopic retrograde cholangiography revealed bile leak through the common hepatic duct, and severe stenosis of the hepatic confluence. A total of three percutaneous transhepatic biliary drainage (PTBD) catheters were inserted to treat obstructive jaundice and cholangitis. The patient was referred to our hospital for surgery 118 days after LC. Cholangiography through the PTBD catheters demonstrated a hilar biliary obstruction. Celiac arteriography revealed obstruction of the right hepatic artery, and transarterial portography showed occlusion of the right anterior portal branch. On the basis of the cholangiographic and angiographic findings, we performed a right hepatic lobectomy with hepaticojejunostomy to resolve the bile duct obstruction and address the problem of major vascular occlusion. The patient's postoperative recovery was uneventful and she remains well 25 months after hepatectomy. We discuss a treatment strategy for bile duct injury suspected after LC, involving early investigation of the biliary tree and prompt intervention. Received for publication on May 17, 1999; accepted on July 12, 1999     

避免腹腔镜胆囊切除术中胆管损伤的手术技巧

目的 探讨避免腹腔镜胆囊切除术（LC）中胆管损伤的方法。方法 对2014年1月至2015年12月我院收治的676例施行LC的临床资料进行回顾性分析。手术技巧包括：前哨淋巴结定位识别胆囊动脉、Rouviere沟引导定位、Calot三角360°解剖、胆囊板分离、吸引器冲洗钝性解剖、果断中转开腹等。结果 本组患者无胆管意外损伤。手术时间30～110 min,平均45 min。11例中转开腹手术,其中4例因腹腔粘连严重,2例因Mirizzi综合征,1例因胆囊结肠内瘘,4例因术中冰冻病理检查提示胆囊癌,遂中转开腹行胆囊癌根治术。术中见2例少见副肝管汇入胆囊管。术后无大出血、胆漏或再次手术等。结论 合理应用手术技巧能有效避免LC术中的胆管损伤。     

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.     

Bile duct injuries during laparoscopic cholecystectomy

Background: With the introduction of laparoscopic cholecystectomy, an increase in the incidence of bile duct injury two to three times that seen in open cholecystectomy was witnessed. Although some of these injuries were blamed on the ``learning curve,' many occurred long after the surgeon had passed his initial experience. We are still seeing these injuries today. Methods: To better understand the mechanism behind these injuries, in the hope of reducing the injury rate, 177 cases of bile duct injury during laparoscopic cholecystectomy were reviewed. All records were studied, including the initial operative reports and all subsequent treatments. Videotapes of the procedures were available for review in 45 (25%) of the cases. All X-ray studies, including interoperative cholangiograms and ERCPs, were reviewed. Results: The vast majority of the injuries seen in this review (71%) were a direct result of the surgeon misidentifying the anatomy. This misidentification led to ligation and division of the common bile duct in 116 (65%) of the cases. Cholangiograms were performed in only 18% (32 patients) of cases, and in only two patients was the bile duct injury recognized as a result of the cholangiogram. Review of the X-rays showed that in each instance of common bile duct ligation and transection in which a cholangiogram was performed the impending injury was in evidence on the X-ray films but ignored by the surgeon. Conclusions: From this review, several conclusions can be drawn. First and foremost, the majority of bile duct injuries seen with laparoscopic cholecystectomy can either be prevented or minimized if the surgeon adheres to a simple and basic rule of biliary surgery; NO structure is ligated or divided until it is absolutely identified! Cholangiography will not prevent bile duct injury, but if performed properly, it will identify an impending injury before the level of injury is extended. And lastly, the incidence of bile duct injury is not related to the laparoscopic technique but to a failure of the surgeon to translate his knowledge and skills from his open experience to the laparoscopic technique. Received: 14 May 1996/Accepted: 1 July 1996     

Delayed presentation of bile duct injuries after laparoscopic cholecystectomy

Bile duct injury is a serious complication of laparoscopic cholecystectomy, with 50% of bile duct injuries showing a delayed presentation. We experienced four patients (one male and three female) with bile duct injuries after laparoscopic cholecystectomy performed and referred by a local practitioner. The patients' ages ranged from 34 to 63 years. Symptoms included abdominal pain, anorexia, jaundice, ascites, ileus, fever, and tarry stool. Ductal injuries were a result of electrocautery burn in two patients and biliary strictures were due to malapplication of endoclips in the remaining two. The observed bile duct injuries, confirmed by ultrasonography, computed tomography (CT) scanning, and cholangiographic studies, were successfully treated by choledochotomy with a silastic T-tube stent. To avoid bile duct injuries, laparoscopic cholecystectomy should be performed by a well trained and experienced hepatobiliary surgeon, who should ensure accurate identification of the anatomical structures of Calot's triangle, careful dissection and management of intraoperative bleeding, and a lower threshold for conversion to open surgery.     

腹腔镜胆囊切除致胆管损伤5例

目的 探讨LC致胆管损伤的原因。方法 回顾性地分析了开展LC以来遇到的5例胆管损伤的具体原因,总结了防止LC致胆管损伤的几点经验。结果 5例中2例于术中发现,分别行“T”管支架引流和端端吻合“T”管支架引流,痊愈而无后遗症。另3例分别行右肝管空肠Roux-en-Y吻合和肝门腔肠Roux-en-Y吻合,其中2例发生逆行感染。结论 LC致胆管损伤最主要的原因并非是由于解剖异常,人为因素、电凝或电钩的盲目使用才是最主要的原因。     

腹腔镜胆囊切除术中医源性胆管损伤的预防

腹腔镜胆囊切除术（LC）目前已定位为良性胆囊疾病的金标准手术。医源性胆管损伤（iatrogenic bile duct injury,IBDI）是其最严重的并发症之一。如发现不及时或处理不当都可能引起严重后果。因此,LC引发的胆管损伤应引起足够的重视。术者经验不足、局部粘连严重、出血、胆道解剖变异等是导致胆管损伤的主要原因。了解LC发生IBDI的风险因素,正确处理IBDI,对避免威胁病人生存质量的后果有非常重要的意义。     

腹腔镜胆囊切除术胆管损伤的特点及诊治

目的 总结腹腔镜胆囊切除术（LC）胆管损伤的特点及诊断和处理的经验教训。方法 回顾性分析23例LC胆管损伤的诊治情况。结果 主胆管损伤12例，其中胆总管横断6例，肝总管横断2例，右肝管横断1例，胆总管横行夹闭1例，胆总管和肝总管裂孔各1例。副肝管损伤儿例，其中迷走胆管损伤1例，细小副肝管损伤7例，较粗大的副肝管损伤3例。本组病例全部治愈。结论 LC较OC（开腹胆囊切除术）更易发生胆管损伤，且损伤更为隐蔽、复杂，处理困难，预后差。首先要争取早期发现，尤其是术中及时发现，根据情况选择恰当的处理方式，避免废弃Oddi括约肌用细薄的正常胆管行胆肠吻合。有分期手术指征的，不勉强行一期手术。胆管吻合后须T管支撑至少6个月。对副肝管的处理须谨慎，不能仅根据其直径粗细作决定，有条件的医院应行术中胆道造影，引流范围小的副肝管才能结扎处理，否则应予修复或重建。不能行术中胆道造影或修复重建困难的，建议先采取副肝管近断端插管外引流的方法。     

Right hemihepatectomy for bile duct injury following laparoscopic cholecystectomy

Laparoscopic cholecystectomy (LC) has become the treatment of choice for patients with symptomatic cholecystolithiasis. But with the introduction of this technique, the incidence of bile duct injuries has increased. We report the case of a 33-year-old man who was transferred from an affiliated hospital to our department for the treatment of a bile duct injury 2 weeks after LC. Prior to transfer, a laparotomy had been performed, with insertion of a T-tube and a Robinson drain on day 5 after LC. Endoscopic retrograde cholangiography (ERC) on admission day revealed an extensive defect of the right biliary system, which could not be treated endoscopically. An emergency laparotomy had to be performed at night for acute bleeding from the portal vein. Due to massive inflammation in the porta hepatis and intraparenchymal destruction of the right bile duct, liver resection was performed 2 days later, after the patient had stabilized in the intensive care unit (ICU). The patient had a prolonged postoperative course, but he finally recovered well from these operations. In conclusion, the management of bile duct injuries should include ultrasound to detect and drain fluid collections and ERC to classify the injury. Emergency laparotomy should never be performed without these examinations, since the majority of bile duct injuries can be treated endoscopically. Surgery for this serious complication should always be performed at specialized centers for hepatobiliary surgery.     

Bile duct injury after laparoscopic cholecystectomy

Background: Forty series reporting experience with laparoscopic cholecystectomy in the United States from 1989 to 1995 were reviewed. A total of 114,005 cases were analyzed and 561 major bile duct injuries (0.50%) and 401 bile leaks from the cystic duct or liver bed (0.38%) were recorded. Intraoperative cholangiography (IOC) was attempted in 41.5% of the laparoscopic cholecystectomies and was successful in 82.7%. In major bile duct injuries, the common bile duct/common hepatic duct were the most frequently injured (61.1%) and only 1.4% of the patients had complete transection. Methods: When reported, most of the bile duct injuries were managed surgically with a biliary-enteric anastomosis (41.8%) or via laparotomy and t-tube or stent placement (27.5%). The long-term success rate could not be determined because of the small number of series reporting this information. The management for bile leaks usually consisted of a drainage procedure (55.3%) performed endoscopically, percutaneously, or operatively. Results: The morbidity for laparoscopic cholecystectomy, excluding bile duct injuries or leaks, was 5.4% and the overall mortality was 0.06%. It was also noted that the conversion rate to an open procedure was 2.16%. Conclusions: It is concluded based on this review of laparoscopic cholecystectomies that the morbidity and mortality rates are similar to open surgery. In addition, the rate of bile duct injuries and leaks is higher than in open cholecystectomy. Furthermore, bile duct injuries can be minimized by lateral retraction of the gallbladder neck and careful dissection of Calot's triangle, the cystic duct–gallbladder junction, and the cystic duct–common bile duct junction. Received: 24 September 1996/Accepted: 28 July 1997