超声刀腹腔镜胆囊切除术胆管损伤的特点和处理

Iatrogenic bile duct injury by using harmonic scalpel in laparoscopic cholecystectomy

目的探讨超声刀无钛夹法腹腔镜胆囊切除术（UHS—LC）胆管损伤的特点、处理方法及预防措施。方法回顾性分析近5年行UHS—LC1863例的临床资料，11例发生胆管损伤，全部经手术修复，随访1～5年。结果11例胆管损伤分别为：右肝管损伤3例，肝总管损伤2例，胆总管横断3例，胆总管穿孔2例，胆总管横断合并左、右肝管同时损伤1例；损伤于手术中发现9例，手术后发现2例。11例患者共施行再手术13次，无胆管狭窄，无死亡病例。结论手术时一定要弄清肝总管、胆总管与胆囊管三者的关系，采用顺逆相结合的方法，遵循“辨-切-辨”原则，腹腔镜下打结技术对术者要求较高，尤其是三孔法LC，过分牵拉Calot三角易造成出血和副损伤，在靠近胆总管的地方尽量使超声刀刀头的背面朝上，并且其背面绝对不能直接接触胆总管，术中及术后早期发现胆管损伤者，应即刻妥善处理。

Objective To investigate the clinical features and management of bile duct injury caused by laparoscopic cholecystectomy by using harmonic scalpel （UHS-LC）, and its prevention. Methods The clinical data of 1863 UHS-LC cases from April 2003 to February 2008 were retrospectively analyzed. There were 11 patients suffering from UHS-LC related iatrogenie bile duct injury including intraoperatively immediate recognized injuries in 9 cases, and postoperatively found injuries in 2 cases. For those patients in which bile duct injury was found during the UHS-LC procedure, the patient was converted to open surgery, the injury was repaired accordingly by end-to-end bile duct anastomosis or Roux-en-Y procedure. For the injuries found postoperatively （ all two cases were of CBD perforation） , CBD was sutured by second stage. Results All the 11 patients recovered well and no biliary stricture occurred during the follow up of 1-5 years. Conclusions While UHS-LC is suitable for most cases of cholecystectomy, it causes significant percentage of bile duct injury （0. 6% ） in hands of unskillful surgeons. It is important to be on alert against iatrogenic bile duct injuries.