有胆道手术史肝胆管结石的腹腔镜胆总管切开取石术的应用

目的 探讨腹腔镜胆总管切开取石术在有胆道手术史的肝胆管结石患者中的应用价值。 方法 2009年3月至2013年3月期间，中航工业三六三医院普外科收治的86例肝胆管结石患者接受了腹腔镜胆总管切开取石术，其中26例既往有胆道手术史（PBS组），60例无胆道手术史（NPBS组）。左肝内胆管结石15例，右肝内胆管结石52例，双侧肝内胆管结石19例。回顾性分析患者围手术期的临床资料。 结果 PBS组与NPBS组手术时间分別为（161.4±31.5） min和（155.7±28.1） min，其差异无统计学意义（P＞0.05）；术中出血量分别为（69.2±50.7） mL及（44.1±27.4） mL，PBS组多于NPBS组（P＜0.05）；PBS组术后并发症发生率为53.8%，尤其是腹腔积液明显多于NPBS组（P＜0.05）；2组总残余结石发生率为15.1%，总结石清除率为98.8%；PBS组术后远期并发症发生率为23.1%，明显高于NPBS组（P＜0.05）。 结论 腹腔镜胆总管切开取石术是有胆道手术史肝胆管结石患者一项安全可行且有效的微创治疗选择，尤其适用于无肝萎缩肝胆管结石、结石弥漫分布合并胆管狭窄的双侧肝胆管结石以及合并胆汁性肝硬变的肝胆管结石。

Application of Laparoscopic Choledocholithotomy on Hepatolithiasis Patients with Previous Bile Duct Surgery

Objective To explore the value of laparoscopic choledocholithotomy on hepatolithiasis patients with previous bile duct surgery contraindicating hepatectomy. Methods Eighty-six hepatolithiasis patients contraindicating hepatectomy accepted laparoscopic choledocholithotomy during March 2009 and March 2013 in the department of general surgery， AVIC 363 hospital. Among them， 26 cases with previous bile duct surgery （PBS group） and 60 cases without（NPBS group）， 15 cases with left intrahepatic bile duct stone， 52 cases with right intrahepatic bile duct stone， and 19 cases with bilateral intrahepatic bile duct stone. Perioperative materials were reviewed between two groups retrospectively. Results The operation time of the PBS group and NPBS group was （161.4±31.5） min and （155.7±28.1） min respectively （P＞0.05）. And the intraoperative blood loss of them was （69.2±50.7） mL and （44.1±27.4） mL respectively（P＜0.05）. Postoperative complication incidence of PBS group was 53.8%， among them， ascites was found obviously much more in PBS group than that in NPBS group （P＜0.05）. The general residual stone incidence of two groups was 15.1%， and the general stone clearance rate was 98.8%. The long term postoperative complication occurrence in PBS group was 23.1%， which was higher significantly than that in NPBS group （P＜0.05）. Conclusion Laparoscopic choledocholithotomy is a safe， effective thus feasible choice for hepatolithiasis patients with previous bile duct surgery， especially for those without hepatic atrophy， bilateral hepatic bile ducts stone with hepatic bile duct stricture and hepatic bile duct stone with coexisting biliary cirrhosis.