肝外胆道手术中胆道损伤的原因分析及处理对策

目的探讨肝外胆道术中胆道损伤的原因及处理方法的选择. 方法对61例肝外胆道术中胆道损伤进行回顾分析.术中及时发现13例:3例右肝管损伤给予对端吻合、T管引流;8例胆总管或肝总管破口者,利用肝圆韧带修复;2例胰头部胆管穿孔者,予Roux-en-Y吻合.余48例为术后发现者:4例保守治疗,21例肝总管、胆总管被部分或完全缝扎者,予拆除缝线、T管引流;5例胆管轻度破口者,予肝圆韧带修复;18例腹腔炎症严重者,予T管引流,3个月后行胆肠Roux-en-Y吻合. 结果经平均2年的随访,本组无死亡病例.术中右肝管对端吻合的3例,术后2例出现轻度胆漏;术中利用肝圆韧带修补8例,术后3例出现轻度胆漏,均经充分引流非手术疗法治愈.术后发现的48例中,经充分引流保守治愈4例;再手术44例,术后3周内治愈20例,4周内治愈6例,另外18例3个月后行胆肠Roux-en-Y吻合,术后1～2个月治愈.合并膈下脓肿3例,肺部感染4例,轻度反流性胆管炎3例,均经抗感染和对症治疗而愈.结论尽早发现、及时处理对提高疗效和防止术后胆管狭窄起着决定性作用.术中发现胆管损伤,应立即进行修补或对端吻合,T管引流.术后数天发现者,则宜行规范的胆肠Roux-en-Y吻合术.

Analysis of Intraoperative Extrahepatic Bile Ductal Injury and the Surgical Approach for Bile Ductal Repair and Reconstruction

Objective To investigate the cause for intra op erative extrahepatic bile ductal injury and the suitable repair and reconstructi on operation. Methods 61 cases of intraoperative extrahe patic bile duct injury were retrospectively analyzed. 13 cases were identified i n the operation: 3 cases of right hepatic ductal injury underwent end-to-end a nastomosis and T-tube drainage; 8 cases with laceration on hepatic duct or com mon bile duct(CBD) underwent repair with round ligament; 2 cases of perforation at retropancreatic head section of CBD underwent Roux-en-Y anastomosis. The r est 48 cases were identified postoperatively, conservative treatment in 4 cases, 21 cases of partially or totally ligated at hepatic duct or CBD underwent T-tu be drainage;5 cases of minor perforation underwent repair with round liganent, 18 cases with severe peritoneal inflammation underwent T-tube drainage temporar ily and choledochojejunostomy 3 months later. Results No death was found in 2 year follow-up. 2 cases experienced slight bile leakage i n 3 cases of right hepatic ductal anastomosis and 3 cases experienced slight bil e leakage in 8 cases of repair with round ligament, all the leakage were cured b y continuous drainage. 4 cases were cured with conservative drainage. 44 cases u nderwent secondary operation, 20 cases were cured in 3 weeks and 6 cases in 4 we eks. 18 cases underwent choledochojejunostomy 3 months later who were cured 1 to 2 months post operation. Subphranic abscess in 3 cases, pulmonary infection in 4 cases, refluxing cholangitis in 3 cases which were cured by anti-infectious t reatment. Conclusions Early diagnosis, early treatment a re essential to improve prognosis and prevent bile ductal stricture. Repair or e nd-to-end anastomosis and T-tube drainage should be performed if the injury i s found intraoperatively. Choledochojejunostomy is suitable for the cases which are identified postoperatively.