腹腔镜胆囊切除术中肝外胆道解剖异常的防范

Diagnosis and Managements of the Anatomic Variation of the Extrahepatic Biliary Tree during Laparoscopic Cholecystectomy

目的探讨腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)中肝外胆道异常的诊断及处理。方法1999年10月～2008年6月1216例LC中,发现15例(1.2%)胆道解剖异常。3例胆囊管异常粗、短,开口在左右肝管汇合部;1例胆囊颈部结石嵌顿,胆总管较细,向上牵拉胆囊使胆总管走行移位;1例胆囊管与肝总管并行后低位开口,1例胆囊管在胆总管右侧回旋扭曲,开口于右肝管侧壁,2例胆囊壶腹部粘连严重,覆盖于胆总管及肝总管前方;3例在胆床附近见迷走胆管走行;3例在分离胆囊管时发现右后肝管开口于肝总管;1例Mirizzi综合征解剖不清。仔细分离,丝线结扎或上钛夹处理,解剖不清者中转开腹。结果13例顺利完成LC;2例(13.3%)中转开腹,其中1例副右肝管损伤,1例Mirizzi综合征。无腹腔内出血、腹腔感染、肠道损伤及死亡等严重并发症。15例随访3个月～4年,其中>1年11例,无胆道狭窄及残余结石。结论LC术中精细解剖胆囊三角,确切辨认各管道关系,是预防胆道异常情况下肝外胆道损伤的关键。

Objective To explore the diagnosis and treatment of anatomic variation of the extrahepatic biliary tree in laparoscopic cholecystectomy （LC）. Methods From October 1999 to January 2008, totally 1216 cases of LC were performed in our hospital, anatomic variation of the extrahepatic biliary tree was found in 15 （ 1.2% ） of them. Among the 15 patients, 3 had wide and short cystic duct with the opening at the junction of the right and left hepatic ducts; 1 patient showed dislocation of a relatively thin choledoch owing to calculus incarceration; 1 case was found having a cystic duct parallel to the common hepatic duct with a low-level opening ; 1 patient had twisted cystic duct at the right side of the common bile duct with an opening at the right hepatic duct ; 2 patients were suffered from massive adhesion in the cystic ampulla that covering the common bile and common hepatic ducts; 3 cases showed aberrant bile ducts lying on the gallbladder bed; 3 patients were found having the right posterior hepatic duct opened to the common hepatic duct; 1 case was diagnosed with Mirizzi syndrome, in whom the anatomical structure was unclear. For all of the patients, the abnormal structures were separated carcfully, ligated with sutures or titanium clips if necessary. Results LC was completed in 13 of the 15 cases, the other 2 patients were converted to open surgery because of the injury to the right hepatic duct or Mirizzi syndrome. None of the series had intra-abdominal bleeding or infection, bowel injury, or death. The patients were followed up for 3 months to 4 years （over 1 year in 11 cases）. None of them developed biliary stenosis or residual calculus. Conclusion Identification of the Calot triangle is crucial to prevent surgical injuries to the extrahepatic biliary tree.