腹腔镜胆囊切除术中医源性胆道损伤的处理策略  

The treatment strategies of iatrogenic bile duct injury in laparoscopic cholecystectomy

作　　者：刘桂杰[1] 薄晓辉 侯旭[1] 高超 赵贵美[1] 李学华[1] LIU Gui-jie;BO Xiao-hui;HOU Xu(Department of Hepatobiliary Surgery,Liaocheng People’s Hospital,Liaocheng 252000,China)

机构地区：[1]聊城市人民医院肝胆外科,山东聊城252000

出　　处：《腹腔镜外科杂志》2020年第6期432-435,共4页Journal of Laparoscopic Surgery

摘　　要：目的:探讨腹腔镜胆囊切除术(LC)中医源性胆管损伤的诊断及处理策略。方法:回顾分析2009年1月至2018年12月19例LC导致的医源性胆管损伤患者的临床资料。按Strasberg-Bismuth胆管损伤分型,胆囊管残端漏或胆囊床小胆管漏(A型)3例(15.8%);副右肝管损伤导致胆漏(C型)2例(10.5%);肝外胆管侧壁损伤导致胆漏(D型)7例(36.8%);肝外胆管横断损伤导致胆管梗阻(E型)7例(36.8%)。术后发现并处理7例,其中行胆管空肠Roux-en-Y吻合治疗4例,行内镜鼻胆管引流、腹腔引流3例。术中发现并处理12例,其中腹腔镜胆管修补1例,腹腔镜胆管修补+T管引流3例,腹腔镜胆囊床小胆管夹闭处理2例,中转开腹行胆管空肠Roux-en-Y吻合3例,胆管端-端吻合+T管引流1例,副右肝管空肠Roux-en-Y吻合2例。结果:19例患者失访2例,随访率89.5%,术后中位随访时间49个月。1例患者经过内镜鼻胆管引流、腹腔引流后胆漏消失,但拔管后出现胆管狭窄、黄疸,于术后5个月再次行胆管空肠Roux-en-Y吻合治愈。全组均无严重并发症及死亡病例。结论:LC相关医源性胆管损伤应根据损伤发现时间、原因、部位及程度等因素进行个体化治疗,及时诊断并由经验丰富的专科医师进行确定性修复手术是改善预后的关键。Objective:To investigate the diagnosis and management measures of iatrogenic bile duct injury(IBDI)in laparoscopic cholecystectomy(LC).Methods:The clinical data of 19 patients with IBDI caused by LC from Jan.2009 to Dec.2018 were retrospectively analyzed.According to Strasberg-Bismuth classification,there were 3 cases(15.8%)with leakage of residual end of cystic duct or leakage of small bile duct in gallbladder bed(type A),2 cases(10.5%)with bile leakage caused by injury of accessory right hepatic duct(type C),7 cases(36.8%)with bile leakage caused by injury of lateral wall of extrahepatic bile duct(type D),7 cases(36.8%)with bile duct obstruction caused by extrahepatic bile duct transection injury(type E).7 patients with postoperative complications were diagnosed and treated,4 cases underwent Roux-en-Y choledochojejunostomy,and 3 cases underwent endoscopic nasobiliary drainage(ENBD)and peritoneal drainage.12 patients were diagnosed in surgery and underwent immediate repair,one case with simple laparoscopic bile duct repair,3 cases with laparoscopic bile duct repair and T tube drainage,2 cases repaired by clipping the small bile duct of the liver bed laparoscopically;conversion to laparotomy was necessary in 6 cases,3 cases underwent Roux-en-Y choledochojejunostomy,one case with end-to-end biliary duct anastomosis and T tube drainage,2 cases with Roux-en-Y right accessory hepatic duct jejunal Roux-en-Y anastomosis.Results:Seventeen patients received follow-up(89.5%),with a median follow-up of 49 months.Bile leak of one case disappeared after ENBD and peritoneal drainage,but biliary stricture and obstructive jaundice occurred after removal of these drainage tubes,and finally this patient underwent Roux-en-Y choledochojejunostomy in 5 months after surgery.No serious complications or death were found.Conclusions:LC related IBDI requires individualized surgical treatment according to the comprehensive factors such as the time of diagnosis,cause,location and extent of the injury.Timely diagnosis and deterministic repa

关 键 词：胆囊切除术 腹腔镜 医源性胆管损伤 诊断 治疗 

分 类 号：R657.4[医药卫生—外科学]