腹腔镜胆囊切除术820例无胆道损伤

How to avoid bile duct injury during laparascopic cholccystectomy:analysis of 820 cases

作者根据连续８２０例腹腔镜胆囊切除（ＬＣ）的实践，介绍避免胆道损伤的经验。本组症状性胆囊结石患者８２０例。其中３７５例行急诊手术。大多数采用硬膜外麻醉，：二氧化碳气腹压力≤１．３３ｋＰａ（１０ｍｍＨｇ）。Ｃａｌｏｔ三角用弯分离钳钝性分离，胆囊床用电钩，有时交替使用分离钳或吸引杆。８０２例顺利完成ＬＣ，术后恢复良好。１３例分别因Ｃａｌｏｔ三角“冰冻化”、出血、胆囊完全萎缩、胆囊管无法夹闭、可疑胆总管结石或钳夹肝总管、胆囊癌等，而中转开腹手术。除胆囊癌１例术后７个月死亡外，其余术后恢复良好，无后遗症。４例手术后１～４天发现胆总管结石再次行开腹手术，作胆总管切开取石。另１例手术后第二天因胆汁性腹膜炎作开腹探查，发现胆囊管残端未完全夹闭。作者主张：（１）在开展此项工作之前应当作适应性训练，并要遵循由简到难的原则；（２）腹腔内操作必须在直视下进行，看清肝管是确保胆管不受损伤的必要条件；（３）Ｃａｌｏｔ三角不用电灼分离，只用分离钳钝性分离；（４）在无把握的情况下或遇到需要开腹才能解决问题时，应当果断中转手术。此外作者还介绍了几点有利于避免胆管损伤的手术技巧。

Laparascopic cholecystectomy(LC)has become the procedure of choice for surgical removal of the gallbladder.The most significant colilplication of this new technique is injury to the bile duct.From July 1994 to April 1996,820 consecutive patients were operated laparascopically at our center.Except for 13 cases who were converted to OPen cholecystectomies when the LC was considered as unsafe the others had succesful LC without bile duct injury. Four patienls were openly reoperated for the retained common bile duct stones,and one for bile leakage which came from the imcompletely clipped cytic duct stump.In our opinoin,bile duct injury during LC is avoidable provided the following points are observed:(1)do some extracorporeal exercises aimed at adapting surgeons to the special circumstances of LC before clinical practice.(2)pay close attention to the anatomy of the bile duct.(3)the Calot's triangle must be blundly dissected by a specially designed dissector,not by the electrical hook.(4)timely convertion to open technique when it is necessary.