内镜联合腹腔镜肝切除术治疗肝内外胆管结石

Combination of endoscopy and laparoscopic hepatectomy in the treatment of intra-and extrahepatic bile duct stones

目的探讨内镜联合腹腔镜肝切除术治疗肝内外胆管结石的方法。方法选择2004年7月至2008年3月南开医院收治的81例肝内外胆管结石患者，其中20例为开腹对照组，其术式为开腹肝切除＋胆道探查术；61例为微创治疗组，其术式为先行十二指肠镜治疗肝外胆管结石。对于取石成功者，根据肝内结石位置，行完全腹腔镜或手助腹腔镜下肝切除术；对于结石无法取尽者，行腹腔镜肝切除＋胆道探查术。采用t检验分析两组围手术期相关指标的变化。结果61例患者均根据结石大小、位置等具体情况实施相应的微创治疗，术后恢复顺利，无严重并发症发生。微创治疗组中手助腹腔镜肝切除＋胆道探查术和开腹对照组的手术时间、术中出血比较，差异无统计学意义（t=0．953，0．911，P〉0．05），胃肠道功能恢复时间比较，差异有统计学意义（t=3．062，P〈0．05）。完全腹腔镜下肝切除术和手助腹腔镜肝切除术的手术时间、胃肠道功能恢复时间比较，差异有统计学意义（t=2．046，2．316，P〈0．05），术中出血量比较，差异无统计学意义（t=0．874，P〉0．05）。结论内镜联合腹腔镜肝切除术治疗肝内外胆管结石是一种安全有效的方法，它能最大限度地减少患者的创伤，充分体现了两者联合治疗的优越性。

Objective To study the approach of the combination of endoscopy and laparoscopic hepatectomy in the treatment of intra-and extrahepatic bile duct stones. Methods Eighty-one patients with intra-and extra-hepatic bile duct stones who had been admitted to Nankai Hospital from July 2004 to March 2008 were divided by random number table into 2 groups. Twenty patients in group A underwent open hepatectomy ＋ biliary exploration. Sixty-one patients in group B received duodenoscopy first, and patients with successful clearance of stones in the extrahepatic bile duct underwent total laparoscopic hepatectomy or hand-assisted laparoscopic hepatectomy accor- ding to the location of the stones in the liver; patients with residual stones in the extrahepatic bile duct underwent hand-assisted laparoscopic hepatectomy ＋ biliary exploration. The changes of the indexes during perioperative period of the 2 groups were analyzed by t test. Results Minimally invasive surgeries were successfully carried out in group B. Satisfactory outcomes were obtained, and no severe complication was observed. The gastrointestinal function recovery time of patients who underwent hand-assisted laparoscopic hepatectomy ＋ biliary exploration in group B was significantly shorter than in group A （ t = 3. 062, P 〈 0.05 ）, but there was no significant difference in operation time and perioperative blood loss between the 2 groups （ t = 0. 953,0.911, P 〉 0.05 ）. Compared with patients who underwent hand-assisted laparoscopic hepatectomy, the operation time was significantly longer, but the gastrointestinal function recovery time was significantly shorter in patients who underwent total laparoscopic hepatectomy （ t = 2. 046, 2.316, P 〈 0.05 ） , there was no significant difference in operation time between the 2 groups （ t = 0. 874, P 〉 0.05）. Conclusion Endoscopy ＋ laparoscopic hepatectomy is safe and effective, and can decrease the trauma to the minimum for patients with intra-and extrahepatic bile duct stones.