肝尾叶胆管结石的术中处治  

Intraoperative management of hepatolithiasis in caudate lobe

作　　者：卢绮萍[1] 史陈让[1] 张兆林[1] 

机构地区：[1]广州军区武汉总医院普通外科,武汉430070

出　　处：《中华肝胆外科杂志》1998年第6期339-341,共3页Chinese Journal of Hepatobiliary Surgery

摘　　要：目的研究肝尾叶胆管结石误诊及净石率低的原因和解剖因素,加强术中处治以改善治疗效果。方法总结1986年8月～1990年6月本院69例肝胆管结石症(Ⅰ组)中18例尾叶结石者误诊及净石率低的主要原因为:(1)尾叶胆管开口多,位置不固定;(2)尾叶胆管走向与胆总管夹角呈一直角,结石易嵌顿;(3)部分肝萎缩及方叶代偿性增生使尾叶开口显露困难;(4)肝尾叶夹于第一肝门和腔静脉之间,为肝外科"风险地带"之一,手术操作困难。对1990年7月～1997年5月期间118例肝胆管结石症(Ⅱ组)中38例尾叶结石者采取的主要改进措施为:在术中 B 超引导下仔细寻找尾叶胆管开口,探查胆道,钳夹、冲洗相结合取石,肝叶切除,显露尾叶胆管,予以彻底的病灶清除等。结果术中净石率由Ⅰ组的57.91%上升到Ⅱ组的85.90%(P<0.01)。结论根据尾叶胆管结石的解剖学特点,在术中 B 超引导下对尾叶结石进行仔细稳妥的术中处治,是提高肝胆管结石手术效果的重要一环。Objective The intraoperative management of clearing concealed stones in the hepatic caudate bile duct branches was taken in order to decrease the rate of residual stones and improve the operative effect. Methods There were 18 patients with caudate lobe hepatolithiasis out of 69 cases of hepatolithiasis treated in our hospital from August,1986 to June,1990 (Group Ⅰ) and 38 patients with caudate lobe bepatolithiasis out of 118 cases of hepatolithiasis treated in the hospital from July,1990 to May,1997 (Group Ⅱ).The main causes of mis- diagnosis and lower rate of clearing stones in Group Ⅰ included:(1)There are many orifices of bile ducts in the caudate lobe and their positions are not fixed;(2) There is a right angle between the caudate bile duct and com- mon bile duct,and the stones are easily incarcerated there;(3) The exposure of caudate lobe bile duct orifices is difficult due to partial atrophy of the liver and hypertrophy of the quadrate lobe;and (4) The caudate lobe is inlaid between the first porta hepatis and vena cava,being one of the 'risk areas' in hepatic surgery.The main improved managements in Group Ⅱ included careful searching and examining orifices and pathway of caudate lobe bile duct under the guide of intraoperative B-mode ultrasonography,holding stones by forceps combined with washing with saline,performing hepatic lobectomy in order to show dilated bile duct and cleating the focus thoroughly.Result The rate of clearing stones increased from 57.9% in Group Ⅰ to 85.90% in Group Ⅱ (P<0.01).Conclusion It is necessary to take conscientiously intraoperative manngement by removing the concealed stones in the caudate lobe bile duct on the basis of anatomic characteristics and under the guide of intraoperative B-mode ultrasonography for improving the treatment efficacy of hepatolithiasis.

关 键 词：肝尾叶 肝胆管结石 术中B超 误诊 解剖学特点 代偿 取石 增生 位置 

分 类 号：R657[医药卫生—外科学] R322.47[医药卫生—临床医学]