腹腔镜联合纤维胆道镜胆总管探查术21例分析

Analysis of laparoscopy combined with fibercholangioscopic choledochotomy in 21 cases

目的总结腹腔镜联合纤维胆道镜治疗胆囊结石合并肝外胆管结石的体会,评估腹腔镜联合纤维胆道镜治疗胆石症的临床疗效。方法回顾性分析21例行腹腔镜胆总管切开探查、纤维胆道镜取石、胆道扩张及T管引流术（laparoscopic choledochotomy T-tube drainage,LCTD）患者的临床资料。结果21例中4例术前行ERCP＋EST,手术成功20例,手术时间70～180 min,平均120min,1例因术中病理示胆囊黏液腺癌,中转开腹行胆囊癌根治术,18例留置T管。患者术后第1天均可下床活动和进食,术后12 d行T管造影夹闭T管。术后30～40 d（平均34 d）拔除T管,2例发生胆漏,其余病例无胆道狭窄、胆道出血和残余结石等手术并发症。1例术后2个月胆管结石复发经T管窦道取石。结论腹腔镜胆总管探查术具有创伤轻、患者痛苦小、康复快、腹腔脏器干扰少等优点,同时能取得与开腹手术相同的治疗效果,是目前微创治疗胆囊结石并复杂性胆管结石较理想的方法,值得推广应用。

Objective To summarize the experiences of laparoscopy combined with fibercholangioscopy for the treatment of cholecystolithiasis and choledocholithiasis and evaluate the clinical curative effect of the method.Methods The clinical data of 21 cases undergone laparoscopic choledochotomy and T-tube drainage were retrospectively analyzed.Results Among 21 cases,4 patients were performed ERCP and EST preoperatively,and operations were succeeded in 20 cases.The operating time was 70～180 min（average,120 min）.1 case was converted to laparotomy because gallbladder mucinous adenocarcinoma was diagnosed by frozen pathological section.T-tube was indwelled in choledochus in 18 cases.Patients could get out of bed and take food on the first day after operation.T-tube visualization and occlusion could be performed in the 12th day,and T-tube was pulled out in 30～40 days（average,34 days）after operation.Bile leakage was found in 2 cases,but no postoperative complications happened in the others,such as stenosis of the biliary tract,hematobilia and residual stone.Calculus of bile duct recurred in 1 case in 2 months after operation,and was removed by fibercholedochoscope through T-tube sinus tract.Conclusion The laparoscopic choledochotomy has many advantages,such as minor damage,less suffering,rapid recovery and less dysfunction of visceral organs,and can achieve the same effects as laparotomy,and is a better minimally invasive treatment for cholecystolithiasis and complicated choledocholithiasis.