腹腔镜手术治疗腹腔镜胆囊切除术后再发胆管结石合并胰腺炎的临床体会

目的:探讨腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)后再发胆管结石合并胰腺炎再次行腹腔镜治疗的可行性、手术时机及手术经验。方法:回顾分析2011年5月至2013年5月20例患者LC术后再发胆管结石合并急性胰腺炎行腹腔镜治疗的临床资料。结果:19例患者顺利完成胆总管探查取石引流术,1例中转开腹,中转率5%。5例患者入院时合并急性胆管炎症状(Charcot三联征)急诊手术,3例为重症胰腺炎予以保守治疗效果不佳,1~3 d内行胆管探查的同时行胰包膜切开灌洗引流术。余者均为轻型胰腺炎未合并急性胆管炎,予以对症治疗待腹痛症状缓解,酶学指标正常后行腹腔镜胆总管探查术。术后2例患者胆管仍有残余小结石,术后3个月经胆道镜取出。结论:LC术后再发胆管结石合并急性胰腺炎再次行腹腔镜胆管探查取石术安全、可行。胆管结石合并急性胰腺炎患者内环境紊乱,病情相对复杂,手术时机的把握、腔镜下胰包膜切开灌洗引流对重症胰腺炎的恢复至关重要。

Clinical application of laparoscopic treatment in patients of recurrent bile duct stone combined with pancreatitis after laparoscopic cholecystectomy

Objective： To explore the feasibility,option and operation experience of laparoscopic treatment in patients of recurrent bile duct stones combined with acute pancreatitis after laparoscopic cholecystectomy. Methods： The clinical data of 20 patients with recurrent bile duct stones combined with acute pancreatitis after laparoscopic cholecystectomy who underwent laparoscopic re-operation from May 2011 to May 2013 were retrospectively analyzed. Results： Nineteen cases underwent laparoscopic common bile duct exploration and lithotomy successfully. 1 case was converted to laparotomy surgery,the rate of conversion was 5%. 5 patients who combined with acute cholangitis symptoms（ Charcot triad） received emergency operation. 3 cases that had severe pancreatitis and poor conservative treatment effect underwent bile duct exploration,pancreatic envelope incision,irrigation and drainage in 1-3 d. The other patients who suffered from mild pancreatitis without acute cholangitis received symptomatic treatment,and laparoscopic common bile duct exploration was performed after remission of abdominal pain symptoms and normalization of enzymology. Small residual stones in bile duct were found in 2 cases postoperatively,and were removed by choledochoscope after three months. Conclusions： Laparoscopic bile duct exploration for patients of bile duct stones combined with acute pancreatitis after laparoscopic cholecystectomy is safe and feasible. Because of the internal environment disturbance and physical condition＇s complexity of recurrent bile duct stones combined with acute pancreatitis,the operation opportunity and the correct way of laparoscopic pancreatic envelope incision,irrigation and drainage are essential for the recovery of severe acute pancreatitis.