上腹部手术史患者行腹腔镜胆总管切开取石术的应用体会  

Experiences on performing laparoscopic choledocholithotomy on patients with previous upper abdominal surgery history

作　　者：刘瑞文[1] 陈健[1] 于亚平[1] 

机构地区：[1]江苏大学附属昆山医院,江苏昆山215300

出　　处：《腹腔镜外科杂志》2013年第10期764-766,共3页Journal of Laparoscopic Surgery

摘　　要：目的：探讨为上腹部手术史患者行腹腔镜胆总管切开取石术的手术方法及应用价值。方法：回顾分析2007年1月至2012年12月为73例有上腹部手术史患者行腹腔镜胆总管切开取石术的临床资料，术中确定结石取净后放置T管。结果．71例顺利完成手术；1例因结石较大嵌顿于胆总管内无法取出，于原手术切口部位做8em切口，用直角钳将结石夹碎后取出；1例因胃癌术后，胆总管移位，合并周围组织水肿，寻找胆管困难中转开腹。手术时间75～190min，平均（119．2±23．1）min，平均住院（6．3±4．4）d，无一例发生胆漏、胆管、肠管、血管损伤等严重并发症。术后6周经T管造影，发现胆道残余结石3例，经T管窦道取出；复查B超，腹腔无积液、感染及脓肿形成。术后随访6个月～5年，随访率71．2％，3例患者于33个月后结石复发，复发率5．8％，均为再手术前合并肝内胆管结石患者。结论：有上腹部手术史患者行腹腔镜手术的难度主要在于腹腔粘连及既往手术对肝门部结构的改变，开展初期应选择粘连程度较轻的患者，逐步积累分离粘连的技巧与信心，逐渐扩大手术适应证，对于减少并发症的发生至关重要。Objective：To explore the methods and application value of performing laparoscopic choledocholithotomy on patients with previous upper abdominal surgery history. Methods： The clinical data of 73 patients with previous upper abdominal surgery history who underwent laparoseopic choledocholithotomy between Jan. 2007 and Dec. 2012 were analyzed retrospectively. T tubes were placed after complete removal of stones. Results：Operations were conducted successfully in 71 of 73 patients. An incision of 8 cm was made in 1 patient and then the stones were smashed and removed by tangential clamp for incarceration ; Conversion to open surgery was conduc- ted in a patient with gastric cancer operation history because common bile duct transposition and tissue edema which made it difficult to find the common bile duct. The operation duration was 75-190 rain, mean （ 119.2 ~ 23.1 ） min. The mean hospital stay was （ 6.3 _＋ 4.4 ） d. No serious complications such as bile leakage, bile ducts,intestine and blood vessels injuries happened. Radiography via T tube was conducted 6 weeks after surgery, and residual stones were found in 3 patients, which were then removed through the sinus tract of T tube. No seroperitoneum,infection or abscess was found by B-ultrasonic examination. The patients were followed up for 6 months to 5 years with a follow-up rate of 71.2%. Recurrence of calculi was found in 3 patients with preoperative intrahepatic bile ducts calculi in 33 months after surgery, and the recurrence rate was 5.8%. Conclusions：The main difficulties of performing laparoscopic choledocho- lithotomy on patients with previous upper abdominal surgery history include adhesion and abnormal anatomic structures of porta hepatis. In the beginning laparoscopic choledocholithotomy should be performed on patients with mild adhesions, and indications can be expand- ed after operating technique and confidence for separating adhesion are improved. This is extremely important for decreasing complica- tions.

关 键 词：胆总管结石 胆总管切开取石术 腹腔镜检查 上腹部手术史 

分 类 号：R657.4[医药卫生—外科学]