腹腔镜胆管损伤157例处理及近期随访分析  

Treatment and Analysis on Laparoscopic Bile Duct Injury in Short-term Follow-up: 157 Cases Report

作　　者：刘昌军[1,2,3] 黄飞舟[2,3] 尹新民[1,2] 毛先海[1,2] 蒋波[1,2] 周海兰[1,2] 吴金术[1,2] 

机构地区：[1]湖南省人民医院肝胆外科,长沙410005 [2]湖南省腹腔镜(普外)治疗质量控制中心,长沙410005 [3]中南大学湘雅三医院普通外科,长沙410013

出　　处：《中国现代手术学杂志》2017年第2期90-93,共4页Chinese Journal of Modern Operative Surgery

基　　金：湖南省自然科学青年基金(2017JJ3172)

摘　　要：目的总结腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)胆管损伤的处理经验。方法回顾性分析2010年1月~2015年7月诊治的157例LC胆管损伤患者临床资料。术中发现70例,行损伤胆管修补、端端吻合;87例术后发现梗阻性黄疸、胆汁性腹膜炎,均接受再次或多次手术。结果本组损伤原因:术中误切、误扎引起88例(56.0%),电凝热效应损伤肝外主要胆管33例(21.0%),胆道变异20例(12.7%),其他因素36例(22.9%)。全组55例行肝胆管盆式Roux-en-Y吻合:3例高位(Ⅳ型)狭窄术后胆管炎反复发作,死于胆汁性肝硬化,52例治愈,术后平均随访3(0.5~5)年,未发生胆管狭窄。102例留置T管,平均术后3个月拔除T管,平均随访2.9(0.5~5)年,其中9例术后再次胆管狭窄,行胆肠Roux-en-Y吻合术治愈;余93例随访0.5~5年,生存良好。结论LC术中胆管损伤多发生在复杂病例,损伤部位愈高,胆管缺损愈大,胆管直径愈细,局部炎症愈重,尤其是电刀离断或烧灼者,解剖损伤胆道残端愈困难。丰富的临床经验,足够的显微外科意识,足够的耐心及毅力是手术成功处理的关键。Objective To assess the treatment experience of bile duct injury due to laparoscopic cholecystectomy（LC）. Methods 157 cases with bile duct injury due to LC were analyzed retrospectively in our hospital during January 2010 to July 2015. 70 cases were found the bile duct injury during the LC and repaired and performed intra-operative end-to-end anastomosis immediately. 87 cases were found postoperative obstructive jaundice and bile peritonitis,and were underwent multiple surgeries. Results The causes of bile duct injury were mis-excision or mis-ligation in 88 cases（56. 0%）,heat effect injury of electric coagulation of main extrahepatic bile ducts in 33 cases（21. 0%）,biliary tract variation in 20 cases（12. 7%） and other reasons in36 cases（22. 9%）. In the 55 patients performed basin type of hepatobiliary Roux-en-Y anastomosis,3 cases were found recurrent high stenosis（type Ⅳ） and died of biliary cirrhosis,and other 52 cases were cured during the 0. 5 to 5（mean 3） years follow-up after the surgery. T tube was indwelled in 102 cases and removed 3 months later.The bile duct stenosis occurred again and cured by Roux-en-Y choledochojejunostomy in 9 patients during 0.5 to 5 years follow-up.The other 93 cases lived well during 0.5 to 5 years follow-up.Conclusions The intra-operative bile duct injury associated with LC always occurred in complex cases.It appeared more difficulty to repair the biliary injury in the case of higher injured site,greater bile duct defect,more detailed bile duct diameter,more severer local inflammation,especially electric knife amputation or burning.Extensive clinical experience,adequate microsurgical consciousness,enough patience and perseverance is the key to successful surgery treatment.

关 键 词：胆囊切除术 腹腔镜 胆管损伤 

分 类 号：R657.4[医药卫生—外科学]