腹腔镜胆囊切除术胆管损伤的诊断与治疗

Diagnosis and treatment of bile duct injury in laparoscopic cholecystectomy

目的：总结腹腔镜胆囊切除术胆管损伤的诊断与治疗经验。方法：分析我院 ６ 年间共诊治的 ２３例腹腔镜胆囊切除术胆管损伤病例。根据胆管损伤的部位和特征，将胆管损伤分为 Ａ～ Ｅ ５ 类；主要检查方法有 Ｂ超、 Ｃ Ｔ、逆行胰胆管造影术（ Ｅ Ｒ Ｃ Ｐ）、经皮肝穿胆道造影术（ Ｐ Ｔ Ｃ）、术中胆道造影术（ Ｉ Ｏ Ｃ）和瘘管造影等 ６ 种；按照胆管损伤类型及发现时间采取不同的治疗措施。结果： Ａ 类：３ 例，表现为胆漏，诊断方法为 Ｂ超或 Ｃ Ｔ，处理方式为局部引流； Ｂ 类：１ 例，无症状， Ｂ 超和 Ｃ Ｔ 示局部胆管扩张，非手术治疗； Ｃ 类（３ 例）和 Ｄ类（２ 例），均表现为胆汁性腹膜炎， Ｅ Ｒ Ｃ Ｐ或经瘘管造影确诊，处理方法为局部胆管缝扎加 Ｔ 管引流； Ｅ 类：１４ 例，主要表现为胆汁性腹膜炎或梗阻性黄疸，通过 Ｅ Ｒ Ｃ Ｐ或 Ｐ Ｔ Ｃ 确诊，手术方式为胆肠吻合术。结论：不同类型的腹腔镜胆囊切除术胆管损伤病例，有不同的临床特点，其诊治手段及预后也不同。

Objective:To summarize our experience in the diagnosis and treatment of biliary injuries after laparoscopic cholecystectomy. Methods: 23 cases were managed in our institute in recent 6 years. All the cases were divided into 5 types from type A to type E on the basis of the clinical findings and treated with different methods accordingly. Results: 3 cases in type A presenting biliary leakage were discovered with ultrasonography or CT scanning and treated with local drainage. 1 case of type B showing no symptoms was found to have distended right hepatic duct on ultrasonography and CT scanning and received conservative measures. All the 3 cases of type C and 2 cases of type D presented the symptoms of generalized peritonitis and diagnosed with ERCP or fistulogram. They were treated with sutures of the leaking duct and T tube drainage. 14 cases of type E presented the symptoms of generalized peritonitis or obstructive jaundice and their clinical findings were verified with ERCP or PTC. They were treated with bilioenterostomy. Conclusion: Patients with different types of biliary injury presenting different characteristics should be diagnosed and treated with different methods accordingly and variable outcomes were obtained.