腹腔镜在胆道损伤修复手术中的临床应用(附9例报告)

Laparoscopy for Reconstruction of the Bile Duct:Report of 9 Cases

目的探讨应用腹腔镜技术修复肝外胆管不同部位、不同程度损伤的可行性。方法 2001年7月~2010年4月,采用如下三种腹腔镜下胆管修复方法治疗肝外胆管损伤9例：①1例左肝管不完全横断伤、1例右肝管不完全横断伤、2例肝总管横断伤、1例胆总管损伤修复后狭窄,采用对端结节外翻缝合左肝管、右肝管、肝总管或胆总管,T管引流术;②3例高位肝管损伤采用Roux-en-Y胆肠吻合,经左或右肝管或肠管放置T管支撑胆肠吻合口;③1例左、右肝管汇合下方肝管前壁10mm直径缺损,采用转移胆囊管壁瓣修复肝管缺损,T管引流术。结果 9例均获治愈,1例肝管对端吻合病例出现胆漏,腹腔引流管引流20 d后愈合。2例高位肝管损伤者行Roux-en-Y胆肠吻合术后出现应激性溃疡和术后腹腔渗血。全组术后随访1~9年,平均4年,无吻合口狭窄。结论腹腔镜在肝胆管修复中有利于视野观察,并且放大较细的肝管,利于精准的缝合操作,从而可以达到最佳的吻合效果。再加上T管对吻合口的支撑作用,最大限度地避免吻合口狭窄的发生,为肝胆管损伤提供了一种精准的吻合方法。

Objective To explore the feasibility of minimally invasive laparoscopic techniques for repairing extrahepatic bile duct injury at different locations with different severities. Methods The following three methods of laparoscopic repair of the bile duct were used in 9 patients from July 2001 to April 2010： ① Nodules eversion suture（end-to-end anastomosis） of the left or right hepatic duct,hepatic duct,or common bile duct plus T tube drainage（1 case of incomplete left hepatic duct transection,1 case of incomplete right hepatic duct transection,2 cases of hepatic duct transection and 1 case of post-common bile duct repair stenosis）;② Roux-en-Y cholangioenterostomy plus insertion of a T tube into the left or right hepatic duct or intestine to support biliary-enteric anastomosis（3 cases of high hepatic duct injury）.③ Cystic duct transfer plus T tube drainage（1 case of hepatic duct defect with 10 mm in diameter at the anterior biliary wall）.Results All the 9 patients were cured.In the patients who underwent end-to-end anastomosis of the hepatic duct developed bile leakage and was cured by peritoneal drainage for 20 days.Stress ulcer and postoperative bleeding occurred in 2 cases of high hepatic duct injury.All the 9 cases were followed up from 1 to 9 years with a mean of 4 years.No anastomotic stenosis occurred during the period. Conclusions With laparoscopy,we may achieve optimal anastomosis for better observation of surgical field and thin bile ducts.T-tube as a supporter can maximally avoid anastomotic stricture and thus provides a precise anastomosis for bile duct repair.