急性胆囊炎行腹腔镜胆囊切除术胆管损伤的原因和处理

目的探讨急性胆囊炎行腹腔镜胆囊切除术（laparoscopic cholecystectomy，LC）胆管损伤的预防和处理。方法回顾性分析我院1999年10月～2008年10月368例急性胆囊炎行LC导致胆管损伤7例的临床资料，根据胆管损伤轻重采取修补或胆总管空肠Roux—en—Y吻合术，并置T管引流。结果5例术中发现胆管损伤均中转开腹，其中1例胆总管横行剪断和1例电灼伤分别于术后12、3个月拔除T管后出现胆管狭窄，再次手术行胆肠Roux—en-Y吻合术治愈；2例电钩伤行胆管修补、T管引流3个月造影示无狭窄拔管治愈；1例胆总管破损严重行胆总管空肠Roux—en—Y吻合术并置T管支撑引流，住院2周带管出院，1个月后经T管胆肠造影显示通畅拔管痊愈。2例术后3～5d出现黄疸，内镜逆行胰胆管造影提示1例胆管狭窄，1例胆管完全闭锁，开腹探查证实为胆总管完全夹闭、肝总管部分夹闭各1例，分别行胆管空肠Roux—en-Y吻合术并置T管支撑引流术治愈。7例随访0．5～6年，平均3．4年，无胆管狭窄、残余结石等并发症发生。无一例死亡。结论只要正确把握手术时机、掌握好手术技巧、及时正确的中转开腹，急性胆囊炎行LC胆管损伤可避免或减少。

Treatment of Biliary Tract Injury in Patients with Acute Cholecystitis Receiving Laparoscopic Cholecystectomy

Objective To explore the prevention and management of biliary tract injury during laparoseopie eholeeysteetomy （LC） in patients with acute cholecystitis. Methods Between October 1999 and October 2008, 368 patients with acute cholecystitis received LC in our hospital, 7 of them developed biliary tract injury during the operation, and therefore underwent the biliary repair or Roux-en-Y anastomosis between the common bile duct and jejunum as well as T-tube drainage. Results Among these 7 cases, 5 cases was converted to open abdominal operation during the procedure of LC, of which 2 cases （ 1 with total bile duct transection and 1 with electric burn of bile duct） showed stenosis of the bile duct in 12 and 3 months respectively after the T tube was removed, and then was cured by a second Roux-en-Y anastomosis. Two of the 7 patients received biliary repair because of electric burn; cholangiography showed no stenosis after 3-month T-tube drainage. In one patient who had severe injury to the common bile duct, Roux-en-Y anastomosis was performed, and then the patient was discharged from the hospital in 2 weeks with the T tube; one month later, re- examination by cholangiography showed that the case was cured. In the 7 patients, jaundice was observed in 2 cases in 3 to 5 days after the surgery; ERCP showed biliary stenosis in one of them, and complete biliary atresia in another. Subsequent abdominal exploration on the two cases revealed complete common bile duct occlusion in one and partially occluded common hepatic duct in the other. Roux- en-Y anastomosis between the bile duct and jejunum combined with T-tube drainage was therefore made on the patients. The 7 cases were followed up for 0.5 to 6 years, during the period, none of them showed biliary stenosis, residual stones or other complications. No patient died during the follow-up. Conclusion Biliary tract injury during LC in patients with acute cholecystitis can be avoided as long as we choose the right time for LC as well as for conversion to an open surgery.