腹腔镜胆总管切开探查术50例临床分析

目的 探讨腹腔镜胆总管切开探查手术的方法与优缺点。方法 选择胆管结石或胆道蛔虫病患者行腹腔镜胆总管切开探查术。结果 本组50例患者中48例术中分别取出直径为0.6-2.9cm的结石1-11sty ,2例患者术中分别取出死蛔虫1、2条。有6例患者因结石嵌顿或取石网故障,术中无法取净结石,其中2例肋缘下作-6cm小切口开腹取净,4例术后经T管窦道取净结石,1例患者中转开腹手术止血。手术时间117.2(45-180)min,术后6.8(3-12)d出院,30例患者术后置T管引流,未置T管即时缝合胆总管20例,其中1例出现轻度胆汁渗漏,结论 腹腔镜胆总管切开探查取石术是较安全的,患者术后痛苦小、恢复快、住院期短,部分患者不置T管即时缝合胆总管更加体现微创效果。     

腹腔镜胆总管切开探查术

目的 探讨腹腔镜胆总管切开探查手术的方法与优缺点。方法 选择胆管结石或胆道蛔虫患行腹腔镜胆总管切开探查术。结果 50例患中48例术中取出直径为0．6-2．9cm的结石1-11枚、2例患术中取出死蛔虫1、2条,有6例患因结石嵌顿或取石网故障,术中无法取净结石,其中2例肋缘下作一6cm小切口开腹取净、4例术后经T管窦道取净结石,1例患中转开腹止血。手术时间117．2(45-180)min,术后6．8(3-12)d出院,30例患置T管引流。未置T管直接缝合胆总管20例,1例出现轻度胆汁渗漏。结论 腹腔镜胆总管切开探查取石术是安全的,患术后痛苦小,恢复快、住院期短,部分患不置T管直接缝合胆总管更加体现微创效果。     

腹腔镜联合胆道镜经胆囊管治疗胆囊结石合并胆总管结石的临床分析

目的探讨应用腹腔镜联合胆道镜经胆囊管行胆道探查治疗胆囊结石合并胆总管结石的临床效果。方法对2014年1月-2015年12月陕西省核工业二一五医院收治的52例胆囊结石合并胆总管结石患者行腹腔镜联合胆道镜经胆囊管胆道探查取石术,观察其临床效果。结果 52例患者中40例顺利完成手术,手术成功率为76.92%。7例改为腹腔镜下胆总管切开取石、T管引流术,5例中转开腹行胆总管切开取石、T管引流术,中转开腹率9.62%。43例患者一次取石成功,占82.69%;剩余9例患者行二次取石,其中行经胆囊管胆道探查取石术者8例,行腹腔镜下胆总管切开取石术者1例。所有患者术后留置网膜孔引流管,术后3~10 d拔除,1例行腹腔镜下胆总管切开取石患者术后出现胆漏,经保守治疗后康复。无胆道出血、胆道感染等发生,平均住院时间(8.24±2.52)d,所有患者均得到随访1年,B超及磁共振胰胆管造影检查肝内外未见结石残留,肝功能胆红素指标正常。结论腹腔镜联合胆道镜经胆囊管进行胆道探查取石术具有创伤小、患者恢复快、并发症少、安全等优点,临床应用需严格掌握其适应证。     

腹腔镜联合胆道镜治疗胆管结石160例

目的:探讨腹腔镜联合胆道镜在胆总管切开取石中的应用方法及疗效.方法:回顾性分析1998-01/2006-12我院160例胆总管结石行胆总管探查、胆道镜取石的临床资料.结果:159例在腹腔镜下顺利完成手术,1例中转开腹.胆总管一期缝合68例,置T管92例,术中取尽结石156例,术后胆道镜取石4例.手术时间70-120(平均115)min,术后住院时间4-11(平均6)d.无胆道出血及腹腔感染,无手术死亡.术后胆漏2例.经再次腹腔镜下缝合与引流治愈.120例随访6-36(平均18)mo,无结石复发和远期并发症.结论:腹腔镜联合胆道镜胆总管探查取石术具有创伤小、恢复快、住院时间短的优点,治疗胆总管结石安全有效.     

胆道镜在胆道手术中的应用

目的探讨胆道镜在胆道手术中的应用价值.方法对经CT、B超、ERCP或MR证实为胆石症的32例胆道手术患者术中进行胆道镜探查,常规开腹切除胆囊或切开胆管将结石取出后,胆道镜经胆囊管残端或胆管切开处插入胆道依次探查左右肝管,肝总管、胆总管.结果32例患者中发现肝管残留结石1例,胆总管残留结石2例,胆总管末端狭窄2例,胆管癌1例.3例残留结石中2例以取石器将结石取出,1例结石嵌顿在乳头开口处,以胆道镜推送至十二指肠内.2例胆总管末端狭窄,给予胆道镜下扩张治疗,减轻了术后因胆总管末端狭窄而导致的不良后果.1例在探查中发现胆总管下端不光滑,有小结节状隆起,取组织病理检查证实为胆管癌而改变术式,避免了再次开腹手术.结论胆道手术时行胆道镜探查,可减少残留结石的发生,并能及时发现其他病理情况,给予相应治疗,减少漏误诊的发生.     

内镜十二指肠乳头切开联合腹腔镜胆囊切除术治疗胆囊结石并胆总管结石

目的探讨运用腹腔镜胆囊切除术联合内镜十二指肠乳头切开术治疗胆囊结石并胆总管结石的方法。方法对胆囊结石并胆总管结石患者,92例行开腹胆囊切除 胆总管切开取石、T管引流术,86例行内镜下十二指肠乳头切开术(EST) 腹腔镜胆囊切除术(LC)。比较两种术式的临床效果、住院时间、并发症等。结果开腹组术中结石取净率为94.8%,住院时间为23.8±7.6d,术后并发胆瘘2例,肝功能衰竭1例,腹腔感染3例,肺部感染1例。内镜组有4例取石失败,改行开腹手术,余均取石成功,取石成功率为94%,住院时间为10.2±5.3d,并发胆道感染2例,十二指肠乳头出血3例。结论与传统开腹胆囊切除 胆总管切开取石、T管引流术相比,EST LC治疗胆囊结石并胆总管结石具有创伤小、住院时间短、患者恢复快、并发症少等优点,临床效果可靠。EST与LC的联合应用可替代大部分开腹胆囊切除 胆总管切开取石、T管引流术。     

两种不同方法治疗胆囊结石并胆总管结石的临床疗效比较

目的比较腹腔镜下胆囊切除术+胆总管切开取石术和开腹胆囊切除术+胆总管切开取石术治疗胆囊结石并胆总管结石的临床疗效。方法将52例胆囊结石并胆总管结石患者按随机数字表法分为腹腔镜组和开腹组,各26例。腹腔镜组(26例)采用腹腔镜下胆囊切除术+胆总管切开取石术+术中胆道镜探查+T管引流术治疗;开腹组(26例)采用开腹胆囊切除术+胆总管切开取石术+术中胆道镜探查+T管引流术治疗,对比两组治疗效果。结果腹腔镜组手术时间长于开腹组,术后疼痛VAS评分、术后止痛药使用率、术后炎性因子[C反应蛋白(CRP)、白细胞介素6(IL-6)、肿瘤坏死因子-α(TNF-α)]水平及术后肛门排气时间、术后住院时间等均低于或短于开腹组,差异均有统计学意义(P 0. 05)。结论腹腔镜下胆囊切除术+胆总管切开取石术创伤较小、应激较轻、术后恢复较快。     

腹腔镜胆囊切除术与小切口胆总管探查术的联合应用

目的探讨腹腔镜胆囊切除联合小切口胆总管探查治疗胆囊结石合并胆总管多发结石。方法本组23例胆囊结石合并胆总管多发结石,均来自2007年12月至2012年7月我院收治患者,采用腹腔镜下切除胆囊并解剖显露胆总管前壁,镜下确定腹壁切口位置,做3～5 cm切口入腹,经小切口切开胆总管,取石钳取石后根据情况用纤维胆道镜/硬性输尿管镜行胆道探查取石。结果本组无1例中转扩大切口手术,手术时间90～160 min,平均（120±10）min;住院时间10～20 d,平均13 d;21例拔除＂T＂管痊愈出院;2例术后＂T＂管造影B超检查右肝管残留结石,带管出院,术后6周经胆道镜取石痊愈;2例肺部感染,伤口均甲级愈合。结论该术式治疗胆囊结石合并胆总管多发结石创伤小,较单纯小切口安全,比全腹腔镜术式节省时间,取石彻底,适合基层医院。     

胆囊结石合并胆总管结石的现代外科治疗模式

微创化理念的迅速普及, 微创设备的高速发展, 外科医师可以熟练的运用各种微创化器械使患者在短期内迅速康复. 胆总管结石的治疗方式也发生了巨大变化, 由传统的开腹胆总管切开取石、T管引流, 转变为腹腔镜下胆总管切开取石一期缝合或腹腔镜下胆总管切开取石、T管引流, 腹腔镜下经胆囊管胆道镜取石,或胆囊切除, 术前或术后应用十二指肠镜取出胆总管结石. 腹腔镜、十二指肠镜、胆道镜的三镜联合应用将会是今后治疗胆囊结石合并胆总管结石的现代外科治疗模式.     

腹腔镜术中联合胆道镜或十二指肠镜治疗胆总管结石

目的总结腹腔镜术中联合胆管镜或十二指肠镜治疗胆囊疾病合并细径胆总管（≤0．8cm）结石的治疗经验。方法首先完成腹腔镜下胆囊切除术。胆管镜法：经胆囊管残端扩张、经胆囊管胆总管汇合部切开或经胆总管前壁切口入路,采用胆管镜取石网取石和液电碎石取净结石,经胆囊管残端输尿管导管胆管引流、T管引流或行胆总管切口即时缝合术。十二指肠镜法：经胆囊管残端插入输尿管导管或斑马导丝至十二指肠腔,经口插入十二指肠镜至十二指肠乳头,针式刀或弓式刀在输尿管导管或斑马导丝指引下对乳头施行切开术,用十二指肠镜取石网或球囊取石。结果191例患者进行了联合治疗。联合胆管镜法治疗117例,术中胆管镜下均取净结石,平均手术时间114min;术后胆漏7例,均经术中常规放置的胆管引流和腹腔引流管引流治愈;术后影像学复查,胆总管切口即时缝合区呈现轻度狭窄影像2例。联合十二指肠镜法治疗74例,68例乳头切开和取石成功,5例乳头切开成功,1例中转为其他术式,平均手术时间97min;术后轻症胰腺炎6例。两组均无肠穿孔、胆管穿孔、大出血、重症胰腺炎等严重并发症,无死亡。结论只要选择病例合适,腹腔镜术中联合胆管镜或十二指肠镜治疗细径胆总管结石是安全、有效且可行的。     

Mirizzi综合征的微创外科治疗

目的 总结应用腹腔镜和内镜联合治疗Mirizzi综合征的初步经验，探讨微创外科对Mirizzi综合征的治疗效果。方法 对21例CsendesⅡ型，Ⅲ型Mirizzi综合征患者，采用内镜鼻胆管引流术（ENBD）配合实施腹腔镜胆囊切除，胆总管探查，胆囊胆管瘘I期缝合修补术（内衬ENBD导管）。结果 19例手术成功，2例中转开腹。术中结石清除率100％，无胆漏，胆道出血等术后并发症。手术时间平均93.6min，术后平均住院9．4d。术后随访18－41个月，未有结石复发。结论 应用腹腔镜和内镜手段，综合治疗Mirizzi综合征在技术上是切实可行的。但腹腔镜下缝合修复胆管壁缺损较困难，适宜在腹腔镜技术较成熟的单位开展。     

腹腔镜下胆道造影术

为探讨腹腔镜下胆道造影的方法和价值，对６００例胆囊结石并慢性或急性胆囊炎（其中４例伴阻塞性黄疸，６例为胆源性胰腺炎）病人行无选择性腹腔镜胆囊切除和常规术中经胆囊管插管胆道造影术。５６８例（９４．７％）完成了术中胆道造影。术中造影发现胆总管病变４２例，其中３２例为术前未曾检查出的胆管异常。全组共发生胆管损伤３例（０．５％）。表明腹腔镜下经胆囊管插管胆道造影成功率高，术中胆道造影具提高手术质量和防止或减少胆管损伤的作用。     

Laparoscopic management of common bile duct stones: Study of 13 cases

In recent years, laparoscopic surgery for common bile duct (CBD) stones has been gaining wider acceptance. We report our experience with the laparoscopic management of CBD stones in 16 patients (9 males and 7 females; mean age, 62 years; range, 27–81 years). We considered two options for the laparoscopic procedures: (1) transcystic CBD exploration for those patients with fewer than 3 CBD stones, 5 mm or less in diameter, in whom the diameter of the cystic duct exceeded that of the CBD stones and (2) choledochotomy with T-tube drainage for other patients, unless a preoperative percutaneous transhepatic cholangio-drainage (PTCD) tube had been inserted. We successfully removed CBD stones by laparoscopic management in 13 of the 16 patients. The procedures employed were laparoscopic choledocholithotomy in 10 patients and laparoscopic transcystic CBD exploration and stone extraction in 3 patients. We converted to open choledochotomy in 3 patients, because of severe inflammation and dense adhesions due to acute cholecystitis in 2 patients and because of wide adhesions due to previous surgery in 1. We conclude that laparoscopic procedure is a safe and effective method for the removal of CBD stones.     

Can common bile duct lithiasis be removed laparoscopically without external biliary drainage?

AIM OF THE STUDY: To evaluate the indications, feasibility and results of laparoscopic treatment of common bile duct stones without biliary drainage.PATIENTS AND METHODS: Between 1992 and 1999, laparoscopic procedures were performed in 70 consecutive patients, mean age 60 +/- 15 years (range: 18-82). Stone removal was attempted via the cystic duct (n=25) or choledocotomy (n=45). The emptiness of the common bile duct was checked by intraoperative cholangiography or endoscopy. After choledocotomy, closure was performed by interrupted or non-interrupted suture with slowly resorbable thread. Transcystic drainage was used whenever necessary.RESULTS: Nine conversions to laparotomy were necessary (12.8%). Among the 61 patients who had an exclusively laparoscopic procedure, 21 were treated via the transcystic route and 40 through choledocotomy. Biliary endoscopy was possible in only 10 of the 21 patients (47.6%) treated via the transcystic route and in all with choledocotomy. No biliary drainage was used in 16 of the 21 patients treated via the transcystic route and in 39 of the 40 treated through choledocotomy. The 30-day mortality was 1/61 (1.6%). Morbidity was 9.8% and 2 patients underwent a second laparoscopic procedure (one fistula on a choledocotomy suture, one hemoperitoneum of unknown origin). An endoscopic sphincterotomy for residual stone was necessary in 4 patients (4/61, 6.5%), 2 after choledocotomy for an unrecognized stone without biliary drainage.CONCLUSIONS: These results confirm the feasibility of laparoscopic treatment of common bile duct stones and suggest it can be performed without biliary drainage in most cases.     

Laparoscopic exploration of the common bile duct through a choledochotomy: Report of three cases

This article reports three cases of totally intraabdominal laparoscopic exploration of the common bile duct via a choledochotomy with extraction of stones. The patients had failed endoscopic retrograde cholangiopancreatography (ERCP) stone extraction because of the size of the stones in two instances, and in the third, because of the presence of a duodenal diverticulum. This procedure is a promising solution to the problem of large common bile duct (CBD) stones in centers which have established laparoscopic cholecystectomy expertise.     

Laparoscopic C-tube drainage via cystic duct following common bile duct exploration

Laparoscopic common bile duct (CBD) exploration has come into practice with the development of laparoscopic techniques and instrumentation. However, the use of a T-tube for biliary drainage lessens the advantages of laparoscopic surgery, i.e., short hospital stay and good cosmesis. We have performed CBD exploration by laparoscopic chledochotomy followed by transcystic biliary drainage using a 6 French vinyl tube (C-tube) instead of a T-tube and primary closure of the choledochotomy. The C-tube could be removed within 7 days postoperatively because the cystic duct was ligated with an elastic thread. Twelve patients with CBD stones were successfully treated by this new technique and there was no morbidity attributable to the procedure.     

Is intra-operative cholangiography necessary during laparoscopic cholecystectomy？ A multicentre rural experience from a developing world country

AIM: To evaluate the feasibility and safety of performing laparoscopic cholecystectomy (LC) in nonteaching rural hospitals of a developing country without intra-operative cholangiography (IOC). To evaluate the possibility of reduction of costs and hospital stay for patients undergoing LC.METHODS: A prospective analysis of patients with symptomatic benign diseases of gall bladder undergoing LC in three non-teaching rural hospitals of Kashmir Valley from Jan 2001 to Jan 2007. The cohort represented a sample of patients requiring LC, aged 13 to 78 (mean 47.2) years. Main outcome parameters included mortality, complications, re-operation, conversion to open procedure without resorting to IOC, reduction in costs borne by the hospital, and the duration of hospital stay.RESULTS: Twelve hundred and sixty-seven patients (976 females/291 males) underwent laparoscopic cholecystectomy. Twenty-three cases were converted to open procedures; 12 patients developed port site infection, nobody died because of the procedure. One patient had common bile duct (CBD) injury, 4 patients had biliary leak, and 4 patients had subcutaneous emphysema. One cholecystohepatic duct was detected and managed intraoperatively, 1 patient had retained CBD stones, while 1 patient had retained cystic duct stones. Incidental gallbladder malignancy was detected in 2 cases. No long-term complications were detected up to now.CONCLUSION: LC can be performed safely even in non-teaching rural hospitals of a developing country provided proper equipment is available and the surgeons and other team members are well trained in the procedure. It is stressed that IOC is not essential to prevent biliary tract injuries and missed CBD stones. The costs to the patient and the hospital can be minimized by using reusable instruments, intracorporeal sutures, and condoms instead of titanium clips and endobags.     

Antegrade biliary stenting versus T-tube drainage after laparoscopic choledochotomy--a comparative cohort study

BACKGROUND/AIMS: Laparoscopic exploration of the common bile duct (LECBD) has been proven to be an effective and preferred treatment approach for uncomplicated common bile duct stones. However there is still controversy regarding the choice of biliary decompression after laparoscopic choledochotomy. METHODOLOGY: This is a retrospective comparison between the use of antegrade biliary stenting and T-tube drainage following successful laparoscopic choledochotomy. During the period between January 1995 and July 2003, biliary decompression was achieved by either antegrade biliary stenting or T-tube drainage based on the discretion of the operating surgeon. For antegrade biliary stenting, a 10-Fr Cotton-Leung biliary stent was inserted through the choledochotomy and passed down across the papilla. The stent position was confirmed by on-table choledochoscopy before interrupted single-layered closure of the common bile duct. Endoscopic retrograde cholangiopancreatography (ERCP) was performed to remove the stent 4 weeks after operation and at the same time to check for any residual stones or other complications like stricture or leak. In the T-tube group, a 16-Fr latex T-tube was used and the long limb was brought out through the subcostal trocar port followed by the same method of bile duct closure. Cholangiogram through the T-tube was performed on day 7 and the tube would be taken off 1 week later (about 2 weeks after operation) if the cholangiogram did not reveal any abnormality. The two groups were compared according to the demographic data, operation time, length of hospital stay and complication rates. RESULTS: During the study period, 108 laparoscopic explorations of the common bile duct were performed in our centre of which 95 were attempted laparoscopic choledochotomies and 13 were transcystic duct explorations. Of the 95 patients with attempted laparoscopic choledochotomy, there were 9 open conversions, 17 laparoscopic bilioenteric bypasses and 6 primary closures of the common bile duct. All of these patients together with those receiving transcystic duct explorations were excluded and the remaining 63 patients having postoperative bile diversion by either antegrade biliary stenting or T-tube drainage were included in this study. Bile diversion was achieved by antegrade biliary stenting in 35 patients whereas 28 patients had T-tube drainage. There was no difference between the two groups in terms of age, clinical presentation, bilirubin level, length of hospital stay, follow-up duration, common bile duct size, size of common bile duct stones, incidence of residual/recurrent stone and complication rate. It was observed that more patients in the stenting group developed bile leak (14.2% vs. 3.5%) and required more intramuscular pethidine injections (182.86 +/- 139.30 vs. 92.81+/-81.15mg, P=0.000). On the other hand, the T-tube group had longer operation time (141.4+/-45.1 vs. 11 1.1+/-33.9 minutes, P=0.006) and had a longer postoperative hospital stay (10.0+/-7.4 vs. 8.8+/-9.3 days, P=0.020) reaching statistical significance. CONCLUSIONS: Postoperative bile diversion by antegrade biliary stenting after laparoscopic choledochotomy is shown to shorten operation duration and postoperative stay as compared to T-tube drainage, but the problem of bile leak needs further refinement of insertion technique.     

腹腔镜联合胆道镜再手术治疗肝内外胆管结石35例分析

目的探讨腹腔镜联合胆道镜再次手术治疗肝内外胆管结石的可行性以及安全性。方法以2008年1月至2012年5月35例接受腹腔镜胆道再次手术的肝内外胆管结石患者作为腹腔镜组,同期50例接受开腹手术的复发性肝内外胆管结石患者作为开腹手术组,采用t检验比较两组患者在术后早期下床活动、肠功能恢复以及住院时间等方面的差异,两组间切口感染率的比较采用χ2检验。结果 35例腹腔镜组病例中32例顺利完成腹腔镜手术,2例因黏连严重中转开腹手术,1例因出现皮下气肿中转开腹。腹腔镜组再次胆道手术平均手术时间148（105～200）min;围手术期均无出血、胆漏并发症。所有病例均行T管引流。术后腹腔引流管置管时间2～5 d,术后住院时间5～8 d。腹腔镜组均无切口感染发生。经统计学分析,在术后早期下床活动时间、肠功能恢复时间、术后住院时间以及切口感染率方面,腹腔镜组明显优于开腹手术组,差异有统计学意义（P〈0.05）。腹腔镜组3例术后2个月因残留结石行纤维胆道镜经窦道取石术。术后随访6～24个月腹腔镜组所有病例未发现结石复发。结论腹腔镜胆道再次手术的创伤小、并发症少、术后恢复快,在掌握适应症的情况下选择适当病例用于治疗肝内外胆管结石是安全有效的。