腹腔镜胆囊切除术后再疼痛的原因分析及预防

Causes and Prevention of Recurrent Pain after Laparoscopic Cholecystectomy

目的探讨腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)后再疼痛的原因及其预防措施。方法回顾性分析2000年1月～2006年1月168例LC术后再疼痛患者的临床资料(非切口创伤引起;LC术后并发症引起;LC术后1年内又出现类似术前症状;LC术前症状符合胆囊炎并胆囊结石症状,而未能进一步完善诊断,术后又出现LC术前相同症状及新发症状,考虑为其他病因引起的LC术前疼痛症状)。并对其术后再疼痛的原因及处理进行总结。结果颈肩痛24例;戳口痛5例;持续性腹腔内疼痛71例,其中28例胆漏,23例继发胆总管结石,6例术后急性胰腺炎,残株胆囊炎和(或)胆囊管残余结石8例,肝下间隙积液感染5例,十二指肠球部溃疡1例;阵发性腹部疼痛32例,其中9例为肠蠕动亢进,23例胆道运动障碍;黄疸并疼痛31例,其中右肝管狭窄肝内胆管局灶性扩张7例,胆管炎10例,肝外胆管残余结石11例,壶腹癌2例,胆总管下端癌1例;胆道蛔虫症2例;腹胀诱发疼痛2例;剧烈恶心、呕吐诱发疼痛1例。168例均症状缓解,其中再手术、ERCP+EST治疗86例,非手术治疗82例。168例随访1～36个月,无其他并发症发生。结论LC术后疼痛的原因涉及到围手术期的每个环节;完善LC术前检查,重视术中术后的每个环节是减少LC术后疼痛的关键。

Objective To investigate the causes and preventive measures of recurrent pain after laparoscopic cholecystectomy （LC）. Methods From January 2000 to January 2006, 168 patients developed recurrent pain after LC. The pain was caused by non-incisional wound, postoperative complications, relapse of preoperative symptoms, cholecystitis complicated with gallbladder stones, or other diseases. The data of the cases were reviewed in this study. Results Among the cases, 24 patients had neck and shoulder pain, and 5 cases complained of puncture pain; 71 cases showed consistent abdominal pain, among which 28 had bile leak; 23 developed secondary common bile duct stones, 6 suffered from acute pancreatitis, and 8 had residual cholecystitis or cholecystic stones; inferior hepatic space inflammatory fluid was detected in 5 cases, duodenal bulbar ulcer in 1 case; and 32 cases suffered from paroxysmal pain in the abdominal cavity, 9 of them were diagnosed as bowel hyperperistalsis, and 23 had biliary dyskinesia; 31 patients had jaundice complicated with abdominal pain, right focal dilation of the intrahepatic bile duct was detected in 7 of them, residual stones in the extra hepatic bile duct in 11 cases, ampullary carcinoma in 2 cases, carcinoma in the inferior bile duct in 1 case, and ascariasis of the biliary tract in 2 cases; two patients developed abdominal pain because of abdominal distension, and one was induced by severe nausea and vomiting. In this series, the symptoms were relieved in all of the cases, 86 of them were cured by a second operation or ERCP plus EST, and the other 82 received conversational therapy. The patient was followed up for 1 to 36 months, during the period, no complications occurred. Conclusions The causes of recurrent pain after LC involve in each component of perioperation procedures.