36例腹腔镜胆囊切除术胆管损伤的原因及处理

目的分析腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）胆管损伤的原因及影响因素,探讨其防治的措施。方法1998年1月-2007年2月,我院行LC 8600例,发生胆管损伤36例。术中发现31例,术后因黄疸、胆漏发现5例。肝总管无缺损横断20例,胆总管横断4例,肝总管游离横断缺损4例,肝总管钛夹不全夹闭3例,胆总管不全夹闭1例,胆囊管与肝总管交汇处撕裂损伤3例,电钩损伤胆总管1例。胆管对端吻合并置T管支撑引流24例,肝总管-空肠Roux-en-Y吻合4例,T管支撑引流4例,胆-肠Roux-en-Y吻合1例,拔除钛夹3例。结果1例胆管对端吻合后2个月后T管拔除,术后胆管狭窄,3个月后行胆-肠Roux-en-Y吻合术;2例因胆管空肠吻合口狭窄,于术后11个月再次行胆管空肠Roux-en-Y吻合。3例三次手术者随访2-3年,未出现胆管炎症状及结石再形成。1例术后反复发作胆管炎、黄疸、肝功损害,经多次住院抗炎、肝功支持治疗及加强预防,随访1年上述症状消失。余32例术后随访8-36个月,平均16个月,未出现任何不适,无胆管狭窄及其他并发症。结论术者对LC潜在危险性缺乏足够重视,盲目扩大手术适应证,手术操作粗糙、疏漏,经验不足,镜下不能正确判断Calot三角关系,器械使用不当,是发生胆管损伤的根本原因。严格掌握手术适应证,强化操作训练,把握中转开腹的时机,可减少胆管损伤的发生。

Causes and Management of Bile Duct Injury during Laparoscopic Cholecystectomy: Report of 36 Cases

Objective To explore the causes of bile duct injury during laparoscopic cholecystectomy and its treatment. Methods From January 1998 to February 2007, totally 8600 cases of LC were performed in our hospital. Bile duct injury occurred in 36 of them, among which, the common hepatic duct was cut in 20 cases, the common bile duct was severed in 4 patients, the common hepatic duct was cut and freed in 4; incomplete clipping of the common hepatic duct or common bile duct occurred in 3 and 1 cases respectively; 3 cases had injury to the conjunction of the cystic duct and common hepatic duct; electrical burn injury happened in 1 patient. Thirty one of the injured cases were detected during the laparoscopic surgery, while the other five were found because of jaundice or biliary leakage. The patients received bile duct repair and T tube drainage （24） , T tube drainage（4） , Roux-en-Y bowel biliary anastomosis （4） , bile duct anastomosis （ 1 ） , or removal of the titanium clips after the accidents. Results One of the patients who received bile duct anastomosis developed biliary stenosis after the T tube was withdrawn in 2 months after the surgery, Roux-en-Y bowel biliary anastomosis was thus performed 3 months later. Two patients who underwent Roux-en-Y anastomosis developed anastomotic stenosis after the operation, and thus received a second anastomosis in 11 months. These 3 patients who received totally 3 operations, were followed up for 2 to 3 years, none of them developed eholangitis or biliary stones. One patient in this series had refractory cholangitis, jaundice, and liver function impairulent, and was cured after 1-year anti-inflammation and liver support therapy. In the other 32 patients, an 8- to 36-month follow-up （mean, 16 months） was achieved, during which none of them showed any complications. Conclusions Bile duct injury can be due to lacking experience and knowledge of the complications of laparoscopic cholecystectomy, inappropriate enrollment of the patients, inaccurate operation, misuse of the surgical instruments, or being unable to discern the Calot＇ s triangle. Strict indications for the operation, advanced training for young doctors, and appropriate timing for conversion to an open surgery are necessary to decrease the rate of bile duct injury.