重视腹腔镜胆囊切除术胆管损伤

腹腔镜胆囊切除术（laparoscopic cholecystectomy，LC）已成为治疗胆囊良性疾病的金标准，但并发症的发生率较开腹胆囊切除术高，胆管损伤（bile duct injury，BDI）是开腹手术的2倍。目前，我国每年开展LC数万例，降低BDI的发生率具有十分重要的临床意义。     

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．     

腹腔镜胆囊切除术中防止胆管损伤的体会

胆管损伤是腹腔镜胆囊切除术(laparoscopiccholecystectomy,LC)较严重的并发症。我院2001年3月~2006年1月共完成LC450例,无一例发生胆管损伤。现将我们的体会报告如下。临床资料1.一般资料:本组共450例,男性153例,女性297例;年龄20~75岁,平均47岁。急诊手术43例(72h内),择期手术407例。胆囊息肉样变20例,慢性结石性胆囊炎335例,胆囊结石并急性胆囊炎54例,胆囊结石并萎缩性胆囊炎40例,术后证实胆囊癌1例。既往有下腹部手术史者20例。并存肝硬变5例,高血压病35例,糖尿病12例。2.手术方法:全身麻醉,气管插管。采用常规四孔法,术中暴露胆囊三…     

腹腔镜胆囊切除术致医源性胆管损伤六例

医源性胆管损伤（iatrogenic bile duct injury,IBDI）是腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）最严重的并发症之一.如发现不及时或处理方式不当均将可能引起严重的后果.我院自2000年1月至2012年12月行LC手术6 000余例,共发生IBDI 6例,经积极处置,效果较好,现报告如下.     

腹腔镜胆道修复重建术治疗腹腔镜胆囊切除术中的胆管损伤

目的腹腔镜手术出现胆管损伤后通常需要中转开放手术修复或二期手术,给患者增加极大的痛苦。能否采用腹腔镜手术的方法修复胆管损伤是一个值得探讨的问题。本研究的目的是探讨腹腔镜修复术治疗术中和术后早期发现的医源性胆管损伤的方法和可行性。方法总结分析2002年11月至2012年12月采用腹腔镜修复重建术治疗的11例术中或术后早期发现的医源性胆管损伤的资料。11例发生在腹腔镜胆囊切除术中（11／1485,0．74％）。男7例,女4例,平均年龄57．4岁（26～70岁）。其中6例为胆管轻度损伤,5例为高位胆管横断的重度胆管损伤。按刘允怡分类法,11例胆管损伤的损伤类型分别是：I型2例,ⅡA型2例,IIIA型2例,ⅣA型3例,ⅣB型2例。9例胆管损伤在术中发现,另2例在术后2d发现。针对不同的损伤类型采用不同的修复方法。2例肝总管部分轻度损伤（UA型）的患者采用镜下缝合修补、T管引流来修复g1例右肝管孔状损伤的患者采用镜下单纯缝合修复;1例胆总管误扎的患者在镜下松解结扎线、胆总管探查、T管引流;1例胆囊床迷走小胆管横断的患者镜下缝扎封闭;1例胆囊颈残余胆漏的患者采用镜下切除残余胆囊、缝扎胆囊管的方法修复;另外5例高位胆管横断伤（肝总管或者左、右肝管横断伤）的患者采用镜下损伤的胆管对端吻合、硅胶支架管内引流的方法修复。结果11例胆管损伤（BDI）患者均完全腹腔镜下一期修复术,无中转开腹手术。术后患者恢复顺利,无腹腔感染、无伤口感染等并发症发生。胆管修复术后平均住院时间是8．9d（5～15d）。患者均获得随访,随访时间8个月-10年不等。11例患者均无胆管狭窄。有1例患者发生过一次胆管炎,CT发现胆总管轻度扩张,行经内镜逆行性胰胆管造影术检查未发现胆总管结石,无胆管狭窄、肿瘤,考虑胆管轻度扩张为十二指肠乳头炎性狭窄引起,行经内镜下乳头括约肌切开术后治愈。其余10例患者无胆管炎、胆管狭窄等长期并发症。结论轻度胆管损伤可以采用镜下单纯缝合修补或T管引流治疗,胆管横断损伤可以采用腹腔镜下胆管对端吻合术、支架引流管内引流管术的治疗。腹腔镜下胆管修复术用于治疗医源性胆管损伤是有效可行的。然而,手术的难度极大,技术要求高,必须由具有丰富的胆道外科手术和娴熟的腹腔镜技术的专家进行手术。     

腹腔镜胆囊切除术中胆管损伤冈素及预防的体会

自从Mouretl987年完成首例LC，LC手术已成为治疗胆囊结石以及胆囊良性疾病的首选方法和金标准。但腹腔镜胆道手术并发症也越来越被内镜外科医生所重视．胆道损伤是LC最主要的并发症．据刘允怡报道．在12500例LC研究中．胆管损伤发生率为0．85％。2000年1月至2005年9月．笔者行腹腔镜胆囊切除术580例．胆道损伤5例。其中胆总管横断1例．胆总管部分损伤4例。现结合文献将胆管损伤因素及预防的体会报告如下。     

腹腔镜下胆囊切除术胆管损伤的预防

我院近5年来施行腹腔镜胆囊切除术1560例，术中采取以肝十二指肠韧带右缘作为手术操作范围的右缘线，有助于术中避免胆管损伤。对解剖关系不清者及时中转开腹手术，其中13例（0．83％）因胆囊三角区冷冻样粘连而中转开腹手术。本组无胆管损伤或死亡病例。     

腹腔镜胆囊切除术胆管损伤的防治

目的避免腹腔镜胆囊切除术胆管损伤的发生。方法回顾分析本院自1999年1月～2005年11月腹腔镜胆囊切除术512例。结果胆管损伤4例。结论严格的术前准备和规范的手术程序可以极大地减少腹腔镜胆囊切除术胆管损伤的发生。     

腹腔镜胆囊切除术中胆管损伤的分析

随着腹腔镜胆囊切除术 (ＬＣ)的广泛开展 ,其手术并发症也日益受到关注。尤其是ＬＣ术中所引起的胆管损伤 ,作为ＬＣ术中严重并发症的一种 ,各医疗单位也在不断地探讨有效的预防和处理的措施 ,但结果并未像ＬＣ初期所预料的那样 ,胆道损伤的发生率并未完全随着ＬＣ开展数量的增加而消失 ,而是稳定在一定水平上〔1〕。因此 ,我们仍有必要在ＬＣ开展初期总结的胆道损伤处置经验的基础上 ,进一步分析ＬＣ大量开展后胆道损伤的具体原因和处理措施。临床资料本文总结ＬＣ所致胆道损伤共 14例 ;其中来源于我院 34 0 0例 ( 1992～ 2 0 0 1年 )ＬＣ…     

腹腔镜胆囊切除术胆管损伤的防治

与开腹胆囊切除术 (ｏｐｅｎｃｈｏｌｅｃｙｓｔｅｃｔｏｍｙ ,ＯＣ)相比 ,腹腔镜胆囊切除术 (ｌａｐａｒｏｓｃｏｐｉｃｃｈｏｌｅｃｙｓｔｅｃｔｏｍｙ ,ＬＣ)胆管损伤的发生率相对较高。Ｄｅｚｉｅ[1] 分析美国 1117家医院的 7760 4病例 ,报道ＬＣ胆管损伤的发生率为 0 .5 9% ;Ｖｅｃｈｉｏ[2 ] 分析美国114 0 0 5病例 ,胆道损伤发生率为 0 .5 %。国内ＯＣ胆管损伤的发生率为 0 .15 %～ 0 .5 % [3 ] ,ＬＣ为 0 .3 2 %～ 0 .91% [4] 。但随着时间的推移 ,国内ＬＣ胆管损伤的发生率已有逐渐下降的趋势 ,1992年经 2 8家医院的调查为 0 .3 1%…     

腹腔镜胆囊切除术中联合括约肌切开取石的研究

目的　探讨腹腔镜胆囊切除术 (LC)中联合应用胰胆镜括约肌切开 (IOES)治疗胆石症的价值。　方法　回顾性分析联合手术治疗腹腔镜胆囊切除术前诊断和术中常规胆道造影确诊的2 7例胆囊结石合并胆总管结石患者的临床效果。　结果　IOES成功率为 96 3% (2 6 /2 7) ;取净结石率 10 0 % (2 6 /2 6 ) ;IOES后 2例发生轻度急性胰腺炎 ;术后平均住院时间 (3± 1)d。　结论　LC联合IOES能一次性有效微创治疗胆囊结石合并胆总管结石疾病     

腹腔镜胆囊切除术胆管损伤修复术预后因素的研究

目的：探讨腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）中胆道损伤的原因、类型、修复方式与预后的关系。方法：对1995年至2006年间因行LC导致胆管损伤6例患者的临床资料进行回顾性分析。结果：5例胆管损伤在术中及时发现并立即处理,其中4例治愈,1例术后1月T管脱落,发生胆管吻合口狭窄,经再次行胆肠Roux-en-Y吻合术治愈;1例胆管壁电热伤,术后发生腹腔、胆道出血,再次手术探查示胆管壁坏死,放置T管支架治愈。结论：LC胆管损伤处理应依据胆管损伤原因、类型,采取正确的处理方式,方可取得良好的远期效果。     

腹腔镜胆囊切除术中胆管损伤的预防

目的总结腹腔镜胆囊切除术中胆管损伤的原因及其防治方法. 方法回顾分析1 000例腹腔镜胆囊切除术临床资料. 结果中转开腹手术15例(1.5%);并发症6例(0.6%),其中胆总管损伤3例,胃穿刺损伤1例,腹壁刺口出血1例,胆漏1例.无远期并发症. 结论胆道牵拉成角是胆管损伤最常见原因.     

Treatment of common bile duct injuries during laparoscopic cholecystectomy: endoscopic and surgical management

The increase of laparoscopic cholecystectomy has resulted in an increase of bile duct injuries. The purpose of this article is to define the types of injury, their occurrence and frequency, and their management by endoscopic and surgical techniques. Three investigations were included in the present study. 1. A 3-year retrospective study among 29 hospitals with 25,007 laparoscopic cholecystectomies. 2. An 8-year prospective study at our institution of 6488 patients. 3. A prospective endoscopic study of 94 patients with injuries and strictures of the common bile duct (CBD) after laparoscopic cholecystectomy. A special classification for bile duct injuries was developed. Among 25,007 patients from 29 hospitals, a total of 74 lesions were detected with an incidence of 0.29%. At our institution, 20 cases were seen (0.29%) with type I, II, and III injuries. The 94 cases managed by endoscopic procedure were submitted to endoscopic retrograde cholangiopancreatography (ERCP) and papillotomy, with placement of several stents 5 to 10 F during 8 months. The results of this procedure have been excellent to good in 76% of the cases up to 3 years of follow-up. According to our previous and present experience, bile duct injuries after laparoscopic procedure are two times higher than after open procedure. The best treatment is the prevention of these injuries by careful surgical technique. If they occur, the best moment to repair them is during surgery. If they are noticed after the operation, endoscopic or surgical procedures can be employed.     

Avoidance of bile duct injury during laparoscopic cholecystectomy.

Common bile duct (CBD) injury during laparoscopic cholecystectomy appears to have a higher incidence than during open cholecystectomy. This may be a function of inadequate instruction, inadequate caution, or inexperience, or may represent an inherent flaw in laparoscopic exposure. The aim of this study was to identify several steps in laparoscopic exposure of the gallbladder, cystic duct, and Calot's triangle to minimize the risk of surgical disorientation and CBD injury. A review of the first 180 laparoscopic cholecystectomies from the author's series was performed. Maneuvers that provided optimal exposure of the critical anatomy were culled from the video record. These maneuvers were (1) routine use of a 30 degree forward oblique viewing telescope, (2) firm cephalic traction on the fundus of the gallbladder to reduce redundancy in the infundibulum of the gallbladder and best expose the cystic duct, (3) lateral traction on the infundibulum of the gallbladder to place the cystic duct perpendicular to the CBD, (4) dissection of the cystic duct at the infundibulum of the gallbladder, and (5) routine fluoroscopic cholangiography. If these steps do not provide the surgeon with comfortable anatomic orientation, the procedure should be converted to open cholecystectomy.     

腹腔镜胆囊切除术中肝外胆管损伤的预防措施

分析10年间行腹腔镜胆囊切除术（LC）715例，其中顺行LC 585例，逆行LC 125例，中转开腹胆囊切除术（OC）5例。LC成功率99.3%（710/715）。无肝外胆管损伤。笔者的经验是，不盲目追求“三管一壶”的完全显露，顺行LC，逆行LC和适时中转OC的结合应用，避免不正确操作以及注意胆囊管的局部解剖变异，是避免LC中肝外胆管损伤的有效措施     

腹腔镜下胆道探查与内镜Oddi括约肌切开取石的研究

目的:探讨腹腔镜胆道探查取石,T管引流术和腹腔镜胆囊切除一期联合内镜Oddi括约肌切开取石治疗胆总管结石合并胆囊结石的临床应用价值。方法:统计分析研究组(77例腹腔镜胆道探查取石即LCH- TD及43例腹腔镜胆囊切除一期联合内镜Oddi括约肌切开取石即LC- EST)与对照组(60例常规开腹胆总管探查即OCHTD)胆总管结石合并胆囊结石患者的临床资料。结果:研究组胆总管结石合并胆囊结石120例中111例行微创手术取得成功,占92. 5%,与对照开腹探查组相比,术后恢复较好,住院时间短,取得了较满意的效果(P<0 .05);研究组中运用LCH -TD的患者较LC EST的患者手术操作时间、术后腹痛、恶心及住院天数差异有显著性(P<0. 05)。两者在胆总管内径及结石大小方面差异亦有显著性(P<0. 05)。结论:LCH -TD与LC -EST两种术式微创,安全且临床疗效可靠,能代替大部分开腹胆总管探查术;腹腔镜胆总管探查取石法总体上优于腹腔镜胆囊切除一期联合内镜Oddi括约肌切开取石法。胆总管直径>1 0cm者行LCH- TD是一种安全可行的方法。若胆总管内径<1cm,且胆总管结石<1 0cm,建议行LC- EST。     

Managing bile duct injury during and after laparoscopic cholecystectomy

Laparoscopic cholecystectomy is now the treatment of choice for gallstones, but there has been concern that bile leakage after a laparoscopic cholecystectomy is more frequent than after an open cholecystectomy. We have experienced 16 patients with bile duct injury after a laparoscopic cholecystectomy. Five patients had a circumferential injurury to the major bile duct, and we employed a converted open technique for biliary reconstruction. The other 11 patients had partial injurury to the major bile duct, and we performed laparoscopic restoration; all 11 of these patients received endoscopic retrograde cholangiography (ERC) on the day after the operation and stenting for biliary decompression and drainage. No complications were identified and the duration of hospitalization in these patients was significantly shorter than in those who had the converted procedure. If intraoperative cholangiography is performed routinely, the presence and form of bile duct injury can be clearly identified, and the decision to restore the site of injury or to convert to the open technique for biliary reconstruction can be made immediately. Received for publication on May 26, 1998; accepted on Aug. 28, 1998