腹腔镜下经胆囊管切开胆总管取石胆道一期缝合术

Laparoscopic Transcystic Choledochotomy and Primary Ductal Closure

目的探讨腹腔镜下经胆囊管切开胆总管取石,胆道一期缝合治疗胆总管结石的可行性。方法 2009年10月～2010年5月对55例胆囊结石合并胆总管结石施行经胆囊管切开胆总管取石胆道一期缝合术。腹腔镜下切除胆囊后,保留胆囊管长1.0～1.5 cm,沿胆囊管纵轴剪开胆囊管前壁至胆总管,再沿胆总管纵轴向下切开胆总管0.3～1.1 cm,经此切口内镜取净胆道结石并判断Oddi括约肌功能是否正常。从胆总管切开处的下方开始,向胆囊管切开处的盲端方向先行黏膜层缝合,然后肌层缝合,距胆总管0.2 cm结扎胆囊管。腹腔放置引流管。结果 55例手术均获成功,胆囊管直径0.3～0.6cm,平均0.45 cm;胆囊管切开长度1.0～1.5 cm,平均1.3 cm;胆总管切开长度0.3～1.1 cm,平均0.5 cm。腹腔引流管留置3～5 d。术前术后MRCP对比胆总管直径无异常改变。1例术后出现胆漏,对症治疗后治愈。术后腹痛、腹胀2例,48 h后缓解。1例术后5 d出现间歇性腹痛,7 d出现黄疸,9 d后腹痛缓解,黄疸消退。术后住院时间7～13 d,平均8 d。55例术后随访1～6个月,平均4.5月,无残余结石及结石复发。结论腹腔镜下经胆囊管切开胆总管取石胆道一期缝合术治疗胆总管结石可行。

Objective To explore the feasibility of removing bile duct stones through an incision on the cystic duct and then suture the incision primarily by laparoscopy. Methods Between October 2009 and May 2010,55 patients with stones in the gall bladder and common bile duct received laparoscopic choledochotomy through the transcystic approach.During the procedure,after cholecystectomy,the remaining 1.0-to 1.5-cm cystic duct was cut longitudinally,and then a 0.3-to 1.1-cm incision was made on the common bile duct to remove the ductal stones;the function of the Oddi＇s sphincter was determined at the mean time.After removing the stones,the mucosal layer of the common bile duct was sutured followed by the muscular layer,from the bottom to the top of the incision until 0.2 cm to the common bile duct at which point the cystic duct was ligated.After the operation,peritoneal drainage tube was placed.Results The procedure was completed in all of the 55 cases.Of the cases,the diameter of the cystic duct ranged from 0.3 to 0.6 cm（mean,0.45 cm）,and the mean cut length on the cystic duct was 1.3 cm（1.0-1.5 cm）.The mean length of the incision on the common bile duct was 0.5 cm（0.3-1.1 cm）.The peritoneal tube was withdrawn in 3 to 5 days after the operation.Compared with the pre-operative MRCP,the diameter of the common bile duct did not change significantly after the procedure.One patient showed biliary leakage,and was cured by conservative therapy.Two patients developed abdominal pain and distension,which was relieved in 48 hours.In one patient,intermittent abdominal pain was shown on day 5 after the surgery,and then jaundice on day 7,both the symptoms were improved on day 9.The patients were discharged from our hospital in 7 to 13 days with a mean of 8 days.They received a follow-up for 1 to 6 months,during which no residual or recurrent calculi were observed.Conclusions Modified laparoscopic transcystic choledochotomy with primary ductal closure is feasible for common bile duct stones.