腹腔镜胆囊切除术胆管损伤的处理

目的探讨腹腔镜胆囊切除术（laparoscopic cholecystectomy，LC）中胆管损伤的处理。方法回顾分析我院1992年3月-2006年10月8876例LC中16例胆管损伤的临床资料，其中胆总管横行剪断4例，电灼伤3例，胆总管部分撕裂伤4例，钛夹误夹5例。胆管裂口修补，T管支撑引流6例；游离两断端，行端端吻合，T管支撑引流3例；胆管空肠Roux—en—Y吻合5例；去肽夹2例。结果1例胆总管横行剪断后行胆管端端吻合，置T管支撑引流3个月，T管拔除3～5个月后因胆管狭窄，再次行胆管空肠Roux—en—Y吻合，术后未出现因胆管狭窄所引起阻塞性黄疸。2例因胆管空肠吻合口狭窄，分别于术后9、11个月再次行胆管空肠Roux—en—Y吻合，再手术后随访2～4年，未出现胆管炎症状、结石再形成。1例胆管完全性夹闭后行胆管空肠Roux—en-Y吻合术后胆道感染，反复发作。余12例均一次性临床治愈，其中10例随访3～4年，未出现任何不适。结论胆管损伤是LC的主要并发症，早期预防和积极处理胆管损伤是防止多次胆道手术的重要举措。

Management of Bile Duct Injuries During Laparoscopic Cholecystectomy

Objective To discuss the management of bile duct injuries during laparoscopic cholecystectomy （LC）. Methods From March 1992 to October 2006, totally 8876 cases of LC were performed in our hospital. Bile duct injury occurred in 16 of them, among which, the common bile duct was mistakenly cut in 4 cases, partly torn in 5, and wrongly clipped in 5, and electrical burn injury happened in 3. The patients received bile duct repair and T-tube drainage （6） , bile duct anastomosis plus T-tube drainage （3） , or Roux-en-Y bowel biliary anastomosis （5） after the accidents. In 2 patients, the titanium clips were removed. Results In one of the patients with the bile duct been cut, bile duct anastomosis was performed, and T-tube drainage was continued for 3 months ; however, 3 to 5 months after the T tube being removed, the patient had to underwent Roux-en-Y bowel biliary anastomosis because of biliary stenosis. No obstructive jaundice occurred in this patient after the Roux-en-Y. Two patients received a second t Roux-en-Y bowel biliary anastomosis owing to anastomotie stenosis. The second operation was carried out 9 or 10 month after the first surgery, and the patients were then followed up for 2 to 4 years. None of them developed cholangitis or calculi during the follow-up. One patient, who suffered a clipped bile duct, underwent Roux-en-Y bowel biliary anastomosis after the LC, but developed recurrent infection of the bile duct after the second operation. Among the 16 patients, 12 were cured, 10 of them were followed up for 3 to 4 years, during which no one showed biliary symptoms. Conclusions Bile duct injury is one of the major complications after LC. Early prevention and intervention are very important to avoid repeated operations.