腹腔镜胆囊切除术致肝外胆管损伤诊治体会

Clinical Experience of Diagnosis and Treatment of Biliary Tract Injury Caused by Laparoscopic Cholangiocystectomy

目的：探索腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)致肝外胆管损伤的产生原因、诊断依据、预防方法、治疗措施和预后。方法：回顾分析1994年6月～2006年4月期间所有LC手术患者临床资料,共3855例,其中发生不同部位和程度的肝外胆管损伤患者14例,发生率为0.36%。全部病例均于LC术中发现并行即时处治,根据肝外胆管损伤的部位和程度,当即开腹行胆管裂伤缝合术、胆管端端吻合术、副肝管结扎术、肝门胆管整形后与空肠吻合术,1例胆管裂伤行经腹壁戳创置管腹腔引流术。结果：1例胆管裂伤因引流不畅、1例胆管端端吻合发生胆管狭窄分别于LC术后2周、7月再次手术行胆总管“T”管引流术、胆空吻合术而治愈。其余12例均1次手术成功,未发生漏诊漏治、误诊误治。全部病例随访2～11年,无后遗症。结论：积累较多临床经验的基础上,LC术中肝外胆管损伤是可以防范的；若出现肝外胆管损伤时也完全可以当即确诊并得以正确处理,疗效也相当理想。相反,LC术后72h,甚至更长时间发现的肝外胆管损伤的诊治是困难和危险的。任何手术方式的总原则是建立永久通畅的胆肠引流。

Objoetive：To explore causation, diagnosis, prevention, treatment and prognosis of extrahepatic biliary duct injury during lapamscopic cholecystectomy （LC）. Methods：The clinical data of 3855 cases of LC from June 1994 to November 2005 were retrospectively analyzed. Among them, 14 cases （0.39 % ） were complicated with extrabepatic biliary duct injuries （BDIs） during LC. All the BDIs patients were found during the LCs operation and treated timely according to difference of the location and the severity of extrahepatic biliary duct injuries, it was performed separately that suturing the split of biliary duct, choledochocholedochostomy, ligatting accessory hepatic ducts , biliary-enteric anastomoses. Results： 1 case of biliary split for a drainage failure in situ and the other one for postoperative stricture were cured by re-operation of T-tube drainage and biliary--enteric anastomoses. The other 12 cases were healed after the first operation. After a follow-up of 2 to 11 years, no evidence of biliary disease has been detected among all the BDI patients. Conclusion： Extrahepatic biliary duct injuries are able to be kept away at LC. If extrahepatic biliary duct injuries could be found timely and treated properly, curative effect is satisfying. On the contrary, If extrabepatic biliary duct injuries were found beyond 72 hours after LC or even longer,its cure is very difficult and dangerous. Operational General principle is to establish forever-smooth biliary-enteric anastomoses.