腹腔镜胆囊切除术中右肝管分支损伤的预防和治疗(附7例分析)

Prevention and management of injury of branch(es) of right hepatic duct following laparoscopic cholecystectomy (a report of 7 cases)

目的:探讨腹腔镜胆囊切除术(LC)中右肝管分支损伤的预防和治疗。方法:回顾分析本院近4年LC术中发生之右肝管分支损伤的诊断和治疗过程及随访情况。结果:2001年5月至2005年4月,我院行LC术中发现或术后发生胆漏、经造影证实为右肝管分支损伤者共7例,其中男2例、女5例。7例均属选择性手术,其中6例呈胆囊周围慢性炎症,粘连明显,5例在术中放置了双腔引流管,术后发现有胆汁引出。另2例系在术中发现于胆囊管切断后,肝面有胆汁溢出;当即中转开腹,行术中造影,发现为右肝管分支畸形受损,直径分别为0.3cm和0.4cm,予对端吻合;置T管作为内支撑,经胆总管引出。5例在术中放置双套引流管的病例中,1例因每日持续有20～100ml胆汁引出,于术后3个月行右肝管鄄空肠Roux鄄en鄄γ吻合,吻合口直径达1cm;4例分别在术后引流1～3个月后自行闭合,并无任何临床症状,肝功能无异常。2例在术中放置内支撑者,于术后9个月拔除T鄄管,恢复良好。结论:右肝管分支的损伤往往与胆囊三角的慢性炎症程度、胆道系统的解剖变异、手术操作不当等因素有关。对术后发现胆漏者,经通畅的引流治疗1～3个月后,大部病例可以治愈,不需进行第2次手术,对引流超过3个月不愈者,需再次手术。

Objective To present our experience in the prevention and the management of injury of branch（es） of the right hepatic duct during laparoscopic cholecystectomy （LC）. Methods Seven patients （5 females and 2 males） were identified as having injury of the above-mentioned branches confirmed by cholangiography in our series of LC between May 2001 and April 2005. Demographic and clinical data, as well as management and outcome were collected for analysis. Results Two patients had the LC immediately converted to open surgery because of emission of bile on the liver surface; an aberrant branch of the right hepatic duct was found cut in both cases, each with a diameter of 0.3 cm and 0.4 cm respectively; a T-tube was placed through the common bile duct and used as a stent after an end-to-end anastomosis of the cut duct; the T-tube was removed 9 months later and the 2 patients were fully recovered. Among the 5 patients who presented biliary leakage after the operation, one patient with persistent biliary leakage underwent a Roux-Y hepaticojejunostomy 3 months after the surgery, and the other 4 patients recovered uneventfully from the percutaneous drainage.Conclusions The incidence of injury of branch （es） of the right hepatic duct during LC might correlate with chronic inflammation around the Calot triangle area, aberrant anatomy of the bile ducts and inappropriate surgical manipulation. The majority of the cases discovered postoperatively could be cured by the trans-abdominal drainage for 1-3 months, and secondary surgery is indicated only in those who do not respond to non-surgical measures.