腹腔镜胆囊切除术中胆囊床胆管损伤的处理

Treatment of bile duct injures in the gallbladder bed during laparoscopic cholecystectomy

目的探讨预防及处理腹腔镜胆囊切除术（laparoscopic cholecystectomy，LC）时胆囊床胆管（包括右肝管分支及迷走胆管）损伤的对策。方法回顾性分析1997年1月～2004年12月2032例LC中15例胆囊床胆管损伤的临床特征、处理方法及效果。结果5例为慢性结石性胆囊炎急性发作，10例为慢性结石性萎缩性胆囊炎。8例右肝管分支损伤，7例迷走胆管损伤。8例用钛夹夹闭损伤胆管，5例缝合损伤胆管，另2例由于裂口较大且靠近右肝管主干而行开腹胆管修补术。术后胆漏1例，引流5d后痊愈。随访半年～3年，平均23个月，症状消失，无黄疸及胆管炎等并发症发生。结论预防胆囊床处胆管损伤的关键是紧贴胆囊壁剥离胆囊，术中及时发现并采用恰当的处理方法可获得较好的结果。

Objective To discuss the prevention and treatment of bile duct injures in the gallbladder bed during laparoscopic cholecystectomy （LC）. Methods A retrospective analysis was made on clinical features, treatment, and curative effects of 15 cases of bile duct injures in the gallbladder bed out of 2 032 cases of LC from January 1997 to December 2004. Results There were 5 cases of acute attack of chronic calculous cholecystitis and 10 cases of chronic atrophic calculous cholecystitis. The location of injury was at the branches of the right hepatic ducts in 8 cases and at aberrant bile ducts in 7 cases. The injury was treated with titanium clipping in 8 cases, primary suture in 5 cases, and open surgery of bile duct repair in 2 cases because the injury was relativly large and the site of injury was near the trunk of the right hepatic duct. Postoperatively, bile leakage happened in 1 case and was cured by drainage for 5 days. Follow-up surveys for 6～36 months （mean, 23 months） showed free of symptoms and no jaundice or cholangitis. Conclusions Surgical dissection closely near the gallbladder wall when mobilizing the gallbladder is the key to preventing bile duct injuries in the gallbladder bed during laparoscopic cholecystectomy. Prompt detection and proper management of the injury have satisfactory curative effects.