腹腔镜胆囊切除术所致胆管损伤的诊治体会

Experience in dealing with bile duct injury due to laparoscopic cholecystectomy

目的探讨腹腔镜胆囊切除术(LC)致胆道损伤的原因、预防及处理。方法回顾性分析2004年～2011年外院转入(16例)及本院发生的(7例)LC致胆道损伤23例患者的临床资料。结果术中发现胆管小裂口损伤或胆管横断伤,经裂口放置T管支撑引流或对端一期缝合并放置T管支撑引流(7例);术后诊断胆管小裂口或横断伤,可行腹腔置管引流+内镜下鼻胆管引流(3例)、择期行胆管断端对端吻合或胆肠吻合并留置支撑管引流(13例),术后支撑管安放6～12个月(中位时间8个月),随访时间1～6年。其中19例恢复良好,3例术后偶发胆管炎,1例胆道狭窄。结论术前把握LC指征、术中辨认胆囊三角关系、操作轻柔是防止医源性胆道损伤的关键。及时发现胆道损伤、选择适宜的修复时机和方式是保证患者恢复和减少并发症的重要因素。

Objective To explore the cause,prevention and treatment of bile duct injury due to laparoscopic cholecystectomy(LC).Methods Clinical data of 23 cases,consisted of 16cases transferred from other hospital and 7 cases caused by our hospital,suffering from biliary injury LC from 2004-2011 were respectively analyzed.Results Among 23 cases,7 cases diagnosed intraoperatively underwent early repair of bile duct by the placement of T tube from the crack or end-end suture with T tube placement,16 cases diagnosed postoperatively including 3 cases underwent drainage of abdominal cavity and ENBD and 13 cases underwent bile duct stump end to end anastomosis or biliary enteric anastomosis and indwelling supporting T tube.Supporting T tubes were left in place in 20 patients for 6-12 months(median time of 8 months) after operations.Twenty-three patients underwent operations,with 19 cases cured,3 cases suffered from occasional cholangitis,1 case diagnosed with bile duct stenosis.Conclusion Master indication of LC preoperatively,identify Calot triangle and manipulate carefully intraoperatively is the key step of prevention of bile duct injury.Timely detection of bile duct injury,appropriate selection of repair time and methods,operation by experienced surgeon can reduce the incidence of postoperative bile duct stenosis.