围肝门胆道手术方式方法的探讨附79例报告

目的探讨围肝门胆道手术的术式选择及手术技巧。方法2003年6月至2007年6月进行的围肝门胆道手术79例，其中肝门胆管癌22例（按Bismuth分型，Ⅳ型16例，Ⅲ型6例）；肝癌侵犯肝门7例；胆囊癌侵及肝门20例；肝移植术后肝门胆管狭窄4例；伴左右肝管起始部病变的肝内胆管结石22例。Ⅲ型Mirrizzi综合征4例。手术中将肝门部分为三个区域：门口、门外和门内，分别使用肝门显露技术、肝十二指肠韧带骨骼化技术和肝门拆开技术来处理，联合应用可显露病灶并切除之。然后通过肝管成形、胆肠吻合等技术完成胆道引流。结果79例患者均顺利完成手术，9例BismuthⅣ肝门部胆管癌获得根治性切除（56．3％）。本组患者均恢复良好，无重大并发症发生，无围手术期死亡病例。平均手术时间3．5h，平均出血量为450ml，大部分患者不需要输血即可以完成手术。切口感染4／79例；肺部感染、肺不张10／79例；胆瘘6／79例，经保守治疗，通畅引流10～28d后治愈。结论围肝门胆管是围肝门手术的核心，门口、门外和门内三技术的联合应用大大地提高了围肝门病灶的切除率，是成功手术的关键之所在。

Techniques of perihilar biliary tract surgery: Report of 79 cases

Objective To discuss the techniques of perihilar biliary tract surgery. Methods The clinical data of 79 perihilar biliary tract operations (June 2003~June 2007) performed at our hospital were summarized. Hilar cholangiocarcinoma was found in 22 cases (according to Bismuth,type Ⅳ 16 cases,type III 6 cases); HCC encroaching on the hepatic hilum in 7; gallbladder carcinoma encroaching on the hepatic hilum in 20; hilar bile duct stricture after orthotopic liver transplantation in 4; intrahepatic lithiasis affecting the right and(or) left hepatic duct in 22; and Mirrizzi syndrome in 4.The perihilar biliary tract was divided into 3 areas, doorway, outdoor and indoor. We used respectively hilar exposure technique, hepatoduodenal ligament skeletonization technique and hilar dismantle technique to cut the focus. Then we used hepatic duct formation and cholangio-jejunostomy technique to deal with bile drainage. Results All patients underwent the operation smoothly. Bismuth Ⅳ hilar cholangiocarcinoma in 9 patients were resected curatively(56.3%). There was no great complication. The perioperation mortality was zero. The average operation time was 3.5 hours. The average blood loss was 450 ml, and most patients needed no blood transfusion. Four cases suffered from cut infection, 10 had pulmonary infection and atelectasis, and 6 had biliary fistula. These complications were cured by expectant treatment after 10~28 days. Conclusions The success of perihilar operation lies in the exposure of the perihilar bile duct. The techniques based on the 3 doorway, outdoor and indoor areas increase the excision rate of perihilar cholangiocarcinoma. It is also the key of successful surgery.