腹腔镜下经胆囊管胆总管切开取石一期缝合的临床应用研究

目的探讨腹腔镜下经胆囊管切开胆总管取石,胆道一期缝合治疗胆总管结石的可行性。方法 2009年10月至2010年10月,对101例胆囊合并胆总管结石患者施行经胆囊管切开胆总管取石胆道一期缝合术。腹腔镜胆囊切除后,保留胆囊管1.0～1.5cm,沿胆囊管纵轴剪开前壁至胆总管,再沿胆总管纵轴向下切开胆总管0.3～1.1cm,经此切口内镜取净胆道结石并判断Oddi括约肌功能是否正常。从胆总管切开处的下方开始,向胆囊管切开处的盲端方向先行黏膜层缝合,后行肌层缝合,距胆总管0.2cm处结扎胆囊管。腹腔放置引流管。结果 101例手术均获成功,胆囊管直径0.3～0.6cm,平均0.45cm;胆囊管切开长度1.0～1.5cm,平均1.3cm;胆总管切开长度0.3～1.1cm,平均0.5cm。腹腔引流管留置3～5d。术前术后磁共振胆胰管造影（MRCP）对比,胆总管直径无异常改变。2例术后出现胆漏,对症治疗后痊愈。1例术后5d出现间歇性腹痛,7d出现黄疸,9d后腹痛缓解,黄疸消退。术后住院时间3～14d,平均住院时间8d。术后随访1～11个月（平均8.5个月）,无残余结石及结石复发。结论改良的腹腔镜下胆总管切开取石胆道一期缝合术治疗胆总管结石安全可行。

Clinical application of laparoscopic choledochotomy transcysficduct and primary ductal closure

Objective To explore the feasibility of extraction of duct stones through incision of cystic duct.Methods After laparoscopic cholecystectomy was applicated from October of 2009 to October of 2010.That the lengthe of cystic duct was 1.0-1.5cm was retained.Cut antetheca from longitudinal axis of duct of gallbladder to the common bile duct and then cut down the common bile duct 0.3-1.1 cm along vertical axis of the common bile duct.Through this incision bile duct stones were removed by endoscopy and the bile duct and Oddi sphincter＇s function was determined.From the bottom of incision of common bile duct to the cystic duct of the blind-side mucous layer suture was first sutured,then the muscular layer sutured 0.2 cm away from the common bile duct,cystic duct was ligated.Peritoneal drainage tube was placed.Results The operation of these 55 cases was successful.In this group the diameter of cystic duct was 0.3-0.6cm（average 0.45cm）.The length of cystic duct incision was 1.0-1.5 cm（average 1.3 cm）.The length of Common bile duct incision was 0.3-1.1cm（average 0.5cm）.Peritoneal drainage was placed for 3-5 days（average 4 days）.The diameter of bile duct had no abnormal changes compared with preoperation by MRCP.Two cases occurred bile leakage,but soon recovered after symptomatic treatment.Two cases occurred postoperative abdominal pain and abdominal distention,but symptomes mitigated after 48 h.One patient appeared intermittent pains after 5days and jaundice after 7 days,but symptoms mitigated and jaundice disappeared after 9 days.The patients stay in hospital after surgery for 3-14 days（average 8 days）,101 cases were followed-up for 1-11 months（average 8.5 months）.Conclusions New operation mode of laparoscopic choledochotomy and primary ductal submucosa closure was feasible.