腹腔镜保胆取石治疗小儿胆囊结石的初步报告

Laparoscopic removal of calculi with preservation gallbladder(a preliminary report)

目的探讨腔镜下微创保胆取石治疗小儿胆囊结石的临床应用价值。方法回顾分析2008年6月至2011年1月采用腹腔镜联合尿道镜微创保胆取石术治疗小儿胆囊结石12例。胆囊多发结石7例,胆囊结石合并遗传性球形红细胞增多症2例。首先经脐部开放置入5 mm Trocar,建立气腹,压力8～12 mmHg,于右肋缘下腹直肌外缘处置入5mm Trocar,腹腔镜下将胆囊底部经右上腹Trocar孔提出腹外,切开胆囊底部约0.5cm,置小儿0°膀胱镜入胆囊,了解胆汁、胆囊黏膜、胆囊腔、胆囊颈、胆囊管和结石位置、数量、质地以及有无嵌顿等,发现结石后用电切环镜下依次取出,小结石可用吸引器吸出及生理盐水冲洗,胆道镜检查确认无结石残留。予36%泛影葡胺胆道造影,观察有无结石残留、胰胆管合流异常等。检查胆囊管开口见有胆汁流出,无出血,5-0PDS线缝合胆囊切口。观察无活动出血、胆漏等,缝合切口。结果 12例患儿中11例保胆取石获得成功,1例3岁患儿术中胆道造影提示胆总管稍扩张,胆囊开口与右肝管,中转行胆囊切除、肝管空肠Roux-Y吻合术,其余11例行腔镜保胆取石术(2例球形红细胞增多症患儿行腹腔镜脾切除)。手术时间30～70 min,平均50.45 min。术后24 h进食,3～7 d(平均4.27 d)出院。保胆成功的11例患儿获得随访3～30个月(平均16.6个月),期间复查B超检查未见结石复发,无特殊并发症。结论对于胆囊功能良好的小儿胆囊结石患儿采用腔镜下保胆取石手术,具有微创、可重复性强的特点,同时保留了胆道的完整性及胆囊功能,提高患儿的生存质量,对小儿的远期生长发育具有积极意义。手术操作简单,术后恢复快、并发症少,全可行。保胆取石是治疗小儿胆囊结石的可行性方法。

【Objective】 To explore the value of minimally invasive surgery for removal of calculus and preservation of gallbladder with laparoscope in children.【Methods】 12 patients with calculus were arranged for the operation,7 boys and 5 girls,the mean age was（57±36.8） m（ranged from 13 months to 11 years）.Two ports were inserted for instruments of size 5 mm.The additional ports were inserted at subcostal region at the right midclavicular line（5 mm）.Under laparoscopic guidance,the gall bladder was exteriorized through the right subcostal port site and cathetered for cholangiograghy.Then,a 5~8 mm incision was created at the fundus of gallbladder.A cystoscope with loop was insert into the gallbladder through the incision.Calculi were removed with the cystoscope.【Results】 The intraoperative cholangiogram showed the dilated common bile duct and the cystic duct is located in the right hepatic duct in 1 case of 3 years old,Roux-Y hepaticojejunostomy was performed by open surgery.The gall stones were removed successfully in other 11 cases,the operation time was 30~70 minutes（mean 51 minutes）.Feeding started the next day.The patients were discharged from hospital between postoperative day 3 and 7.The 5 patients were followed up for 3~30 monthes,no severe complications were noted,B ultrasonagraphy showed no gall stone recurrent after operation.【Conclusions】 Clinical application of laparocope for removing calculi and conserving gallbladder in children is minimally invasive and produces good outcomes,and it is worth to be introduced.