胆囊结石合并胆总管结石260例报告

目的总结腹腔镜胆囊切除联合胆总管探查术(laparoscopic common bile duct exploration,LCBDE)治疗胆囊结石合并胆总管结石的经验。方法 2005年1月~2008年5月对260例胆囊结石合并胆总管结石行腹腔镜胆囊切除联合LCBDE,全麻后平卧位,采用四孔法。游离胆囊管及胆囊动脉后施血管夹后夹闭,显露胆总管,电凝钩切开胆总管长度约1.5~2.5 cm,取出胆管结石放置于标本袋内,胆道镜检查无结石残留,置入T管于胆总管内间断缝合固定。切除胆囊,取出胆囊、标本袋,经T管注水检查无渗漏,放置腹腔引流,缝合切口。结果成功254例,成功率97.7%(254/260),手术时间70~230 min,平均126 min。中转开腹6例:3例因胆囊三角纤维化严重,呈"冰冻状",无法解剖而中转开腹;1例术中证实Mirizzi综合征而中转开腹;1例因结石嵌顿于胆总管下段无法镜下取出而中转开腹;1例剥离胆囊床时位置靠深,损伤肝中静脉分支,出血汹涌而中转开腹。术后3例出现胆漏,经保守治疗后2~6 d痊愈。1例胆管充满泥沙样结石术后并发寒战、高热,体温高达41.0℃,抗感染、对症治疗体温正常。1例术后3周经T管造影检查证实残留结石1枚,8周后经窦道用胆道镜取出结石。254例术后住院时间6~19 d,平均9 d。223例随访13~24个月,平均16个月,无胆道狭窄等并发症出现,1例术后22个月出现腹痛、黄疸、高热,MRCP证实胆道结石复发,经EST取出结石。结论严格筛选病例,熟练掌握软硬镜技术及细致的术中操作是开展此手术的关键。

Common Bile Duct Stone Complicated with Cholecystolithiasis in 260 Cases

Objective To summarize our experience on laparoscopic common bile duct exploration（LCBDE） combined with LC. Methods Totally 260 cases underwent LCBDE combined with LC from January 2005 to May 2008 in our hospital.All the patients underwent peritoneoscopy by using four trocars under general anesthesia.After separating the cystic gall duct and cystic artery,we occluded the artery to expose the common bile duct.To move stones from the bile duct,we made a 1.5-to 2.5-cm incision at the bile duct.Afterwards,the bile duct was explored with choledochoscopy,a T-tube was indwelt,and LC was performed. ResultsThe procedure was successfully completed in 254 cases with a success rate of 97.7%（254/260）.The mean operation time of this series was 126 minutes（ranged from 70 to 230 minutes）.Six patients were converted to open surgery because of serious fibrosis of the Calot＇s triangle（3 cases）,Mirizzi syndrome（1 case）,the calculi incarcerated in the inferior segment of the common bile duct（1 case）,and injury to the middle hepatic vein（1 case）.Three patients developed bile leakage during the operation and was then cured by conservative therapy.One patient,who had overflowed calculi in the common bile duct,showed high fever（41.0 ℃） and shivering after the operation,and was cured by anti-inflammation and conservative therapies.Three weeks after the operation,T-tube cholangiography showed residual stone in one patient,the stone was then removed by choledochoscopy.The 254 patients were discharge from hospital in 6 to 19 days after the operation（mean,9 days）;223 of them were followed up for 13 to 24 months（mean,16 months）,during which no complications including biliary stricture were detected.One patients showed abdominal pain,jaundice and high fever at 22 months during the follow-up,MRCP then showed recurrent stones,and EST was thus performed to removed the calculi. Conclusion Strict case screening and techniques of laparoscopy and choledochoscopy are the keys to LCBDE.