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。

Application of Laparoscopic Ultrasonography in Laparoscopic Cholecystectomy and Common Bile Duct Exploration

To Study the value of laparoscopic ultrasonography (LUS)in laparoscopic cholecystectomy and common bile duct exploition(LCBDE) , and explore a new minimally invasive technique for the diagnosis and management of chole-docholithiasis. LUS has been routinely applied in 320 laparoscopic cholecystectomies within 2 years, with a comparison of LUS and intraoperative cholangiography (IOC) in 50 cases; ERCP/EST and LCBDE with T- tube drainage or primary duct closure were performde on patients with choledocholithiasis. The mean time taken for the examination of LUS was 15min. Accurate identification of the biliary anatomy and vascular structures was made possible by LUS including visualizations of gallbladder and portal vein(with 100% ) ,hepatic and common bile ducts(98% ) , and the end of CBD(86% ) . The unsuspected CBD stones of 3% and 10% anatomical anamolies of cystic duct were also detected by LUS. LUS was shown to be superior to IOC for the detection of stones: the sensitivites, specificities, and accuracies were 83,98, and 98% by LUS, and 76,95,and 95% by IOC,respectively.The successful rate of ERCP/EST was 90% , and the LCCBDE was successfully performed on 30 patients with T - tube insertion in 25 cases and primary duct closure in 5 cases, and with no occurrence of biliary leadage and injury. The retained stones were cleared out by the use of flexible choledochoscope vie the T - tube tunnel. LUS when routinely performed during LC can be useful in preventing the bile duct injury by delineating biliary anatomy and anomaly, and reducing the rates of retained stones and negative CBDE by detecting or excluding unsuspected bile duct stones. LCCBDE either with T - tube drainage or primary duct closure under the guidant of LUS is a safe, efficient, and reliable new minimally invasive technique for the management of bile duct calculi.