腹腔镜胆总管探查取石术治疗细径胆总管结石148例

Laparoscopic common bile duct exploration and removal of stones from a tiny choledochus： a report of 148 cases

目的总结运用腹腔镜胆总管探查取石术治疗细径胆总管结石的治疗经验。方法完成腹腔镜胆囊切除后，经胆囊管残端扩张、胆囊管胆总管汇合部切开或经胆总管前壁切口入路，采用胆管镜取石网取石、液电碎石、经胆囊管残端输尿管导管胆管引流、T管引流或胆总管切口即时缝合等，有选择地对148例胆总管内径≤0．8cm的细径胆总管结石病人进行治疗。结果腹腔镜胆总管探查取石术148例中，腹腔镜手术成功116例，中转为术中十二指肠镜下乳头切开取石术32例，无中转开腹。术中胆管镜下取净结石116例，十二指肠镜下取出结石29例，乳头切开术后排出结石3例。无残余结石。术后胆漏7例，均经术中常规放置的胆管引流和腹腔引流管引流治愈。术后轻症胰腺炎3例。术后经输尿管导管胆管造影有2例呈现胆总管切口即时缝合区狭窄影像，未予处理。术后其他并发症均经非手术综合疗法治愈。无肠穿孔、胆管穿孔、大出血、重症胰腺炎等严重并发症，无死亡。结论只要选择合适的病例，腹腔镜胆总管探查取石术治疗细径胆总管结石，对于有较高腹腔镜和内镜技术者是可行、有效和安全的。

Objective To summarize the experience in removal of stones from a tiny choledochus by laparoscopic common bile duct exploration （LCBDE）. Methods From October 1993 to July 2008, there were 148 cases of cholelithiasis in tiny choledochus that common bile duct diameter was equal to 0.4-0.8 cm undergoing LCBDE, involving choledochotomy, choledochoscopic exploration, electrohydralic lithothipsy, ureteral catheter through cystic duct remnant for drainage of bile duct, T-tube drainage, the primary closure of duct incision. Results The procedure was successful in 116 out of the 148 cases and it was shifted to duodenoscopic papillotomy during the course of laparoscopy in 32 cases. No cases were shifted to open CBD exploration. No cases had residual stones. Bile leakage was cured with patent drainage in 7 cases. Three patients had slight pancreatitis postoperatively. Two patients had bile duct stenosis of primary closure of duct incision. No cases had perforation of intestine and bile duct, bleeding, severe pancreatitis and death postoperatively. Conclusion If patients are suitable, LCBDE is safe and effective in the hands of skilled endoscopiests.