腹腔镜胆囊切除术预防胆管损伤的术式研究

目的探讨改良术式对腹腔镜胆囊切除手术预防胆管损伤的影响。方法选取2013年3月~2014年3月收治的100例良性胆囊疾病患者,术前磁共振胰胆管造影(magnetic resonance cholangiopancreatography,MRCP)显示:肝外胆管显示清楚者92例(92%);胆囊管显示清楚者85例(85%);左右肝管低位汇合者4例,胆囊管汇入右肝管1例(见图1),副肝管汇入胆囊管者1例。均采取改良的三步法腹腔镜胆囊切除术,即第一步处理胆囊动脉、第二步剥离胆囊、第三步处理胆囊管。术后每2 h观察有无腹痛、发热、黄疸等表现,连续观察3 d,术后第3 d进行肝功能和超声检查,观察是否有急性胆管损伤发生。术后1、3、6个月随访观察有无迟发性胆管损伤。结果术中发现胆囊管变异5例,其中胆囊管极短者1例;胆囊管汇入右肝管者2例;胆囊管汇入右后叶肝管者1例;副肝管汇入胆囊管者1例,100例患者中有96例(96%)成功实施了改良的手术方式,有4例患者(4%)未能实现最后切断胆囊管的操作步骤;平均手术时间(42.74±10.53)min。住院期间未发生出血、胆漏、腹痛、腹腔感染等胆管损伤及其他并发症发生,术后平均住院时间为(3.36±0.72)d。术后1、3、6个月进行的体检、肝功能和腹部超声检查结果显示胆总管轻度扩张16例,无腹痛、黄疸及肝功能异常等迟发性胆管损伤情况发生。结论改良的手术方式能够有效地预防腹腔镜胆囊切除术中胆管损伤的发生,具有重要的临床价值。

Operation Research of Prevention of Bile Duct Injury in Laparoscopic Cholecystectomy

Objective To explore the efficacy of the modified approach of the laparoscopic cholecystec- tomy on the prevention of bile duct injury. Methods 100 patients with benign gallbladder diseases admitted in our hospital from March 2013 to March 2014 were selected. The preoperative magnetic resonance cholangiopancreatography（MRCP） showed 2 cases of gallbladder duct anatomical variation, with one case＇ s gallbladder duct linked to the right hepatic duct, and another case＇ s accessory hepatic duct linked to gallbladder duct. And all of the patients received the modified approach of the laparoscopic cholecystectomy （three-step method）. The first step was to process the gallbladder artery, the second step was to peel off the gallbladder, and the third step was to process the cystic duct. The clinical manifestations were observed such as abdominal pain, fever and jaundice postoperatively every 2 hours for continuous 3 days, liver function and ultrasound were examined 3 days after operation so as to confirm the acute bile duct injury. And late-onset bile duct injury was investigated at the follow-up of 1, 3, and 6 months. Results It was discovered of 5 cases of gallbladder duct anatomical variation intraoperatively, including the two cases discovered preoperatively, and one case of extreme-shortgallbladder duct, one case of gallbladder duct linked to the right hepatic duct, and one case of gallbladder duct linked to the fight posterior lobe hepatic duct. There were 96 patients （96%） successfully completed the modified approach of the laparoscopic cholecysteetomy with operation time of（42.74 ± 10.53 ） minutes, and no bile duct injury or other complications happened. There were 16 cases with mild expansion of common bile duct according to the 1-, 3-, and 6-month follow-up, and no late-onset bile duct injury occurred. Conclusion The modified approach of the laparoscopic choleeystectomy can effectively prevent the bile duct injury, and is worthy to be generally used.