腹腔镜辅助下肝门部胆管癌根治术38例

目的探讨腹腔镜辅助下肝门部胆管癌根治切除术的可行性。方法五孔法。切除胆囊、肝左内叶下段的肝组织,中上段胆管,切断距肿瘤1 cm处的肝侧胆管。清除肝固有动脉、门静脉周围的纤维脂肪组织及淋巴结。左、右肝管盆式成形,左上腹辅助4～5 cm小切口腹腔外胆肠Roux-en-Y吻合。结果 38例肝门部胆管癌根治术均在腹腔镜下完成。5例肠间吻合于镜下使用吻合器完成;33例先扩大左上腹小切口于腹外吻合后还纳回腹,重新气腹完成胆肠吻合。手术时间210～348 min,（267±47）min;术中出血10～210 ml,（82.6±63.5）ml。术后出现胆漏3例,未特殊处理,3～5 d后停止;应激性溃疡1例,抑酸药物治疗后3 d治愈;术后出血1例,在腹腔镜下手术止血。术后住院10～15 d,平均12 d。17例术后1周CEA均恢复正常,2.7～3.5μg/L,（2.73±0.49）μg/L;38例CA199术后均下降,但未恢复正常,40～90 U/ml,（69.4±20.1）U/ml。术后35例（92.1%）随访6～30个月,（12.5±5.8）月,1例术后12个月因转移癌死亡,1例术后15个月因突发心肌梗塞死亡,其余33例随访期间未见明确转移病灶。结论腹腔镜辅助下肝门部胆管癌根治切除术是可行的,在达到根治切除目的前提下,减轻手术创伤,利于术后康复,术者应同时具有开腹和腹腔镜手术的经验和技巧。

Laparoscopic-assited Radical Resection of Hilar Cholangiocarcinoma : Report of 38 Cases

Objective To explore the feasibility of laparoscopic-assited radical resection of hilar cholangiocarcinoma.Method Five-port laparoscopy was used to remove the gallbladder,inferior segment of the left medial lobe of the liver,and the upper and lower bile ducts.Transection of the bile duct was made 1 cm proximally away from the tumor.And the fibro-fatty tissues were also removed so that the lymph nodes around the proper hepatic artery and portal vein can be resected.The left and right hepatic duct basin shape and biliary-enteric Roux-en-Y anastomosis were then completed.Results Radical resection of hilar cholangiocarcinoma was completed laparoscopically in all the patients.Anastomotic stapler was used in 5 cases for enteroenterostomy.In the other 33 cases,enteroenterostomy was performed extracorporeally through a dilated small incision on the left upper quadrant.Then choledochojejunostomy was performed laparoscopically after pneumoperitoneum reconstruction.The procedure was finished within a mean of(267±47) min(210-348 min) with an intraoperative blood loss of(82.6±63.5) ml(10-210 ml).Biliary leakage was found in 3 patients after the procedure;they were all cured spontaneously in 3 to 5 days.Stress ulcer was developed in one patient,who was cured by taking anti-acids for 3 days.Laparoscopic hemostasis was made in one patient because of postoperative hemorrhage.The patients were discharged from hospital in 10 to 15 days(mean,12 days),after the operation,17 of them recovered normal CEA in one week [2.7-3.5 μg/L,mean,(2.73±0.49) μg/L];CA199 was decreased in all the 38 patients,but none of them returned to a normal range [40-90 U/ml,(69.4±20.1) U/ml].Follow-up was achieved in 35 of the patients(92.1%) for 6-30 months(mean,12.5±5.8),during which two patients died of recurrent carcinoma(in 12 months) or myocardial infarction(in 15 months),no metastasis was observed in the other 33 patients who survived.Conclusions Laparoscopic-assited radical resection of hilar cholangiocarcinoma is feasible and less traumatic,which is good for postoperative recovery.Only doctors with experience in both open and laparoscopic surgeries are recommended to perform the procedure.