腹腔镜胆囊切除术中Mirizzi综合征的诊断、处理及疗效分析

Diagnosis,Treatment and Outcomes of Mirizzi Syndrome in Laparoscopic Cholecystectomy

目的探讨腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)中Mirizzi综合征的诊断、处理方法及疗效。方法我院2003年10月～2010年9月行LC时发现Mirizzi综合征22例,对术中诊断、手术方式及治疗效果进行总结。结果按Csendes分型,Ⅰ型13例,Ⅱ型6例,Ⅲ型2例,Ⅳ型1例。14例完成LC,均为Ⅰ～Ⅱ型病例。中转开腹手术8例。术前行ERCP检查7例,均未发生胆管损伤;术中胆管损伤6例,2例行胆管端端吻合术,4例行胆管瘘口修补术。1例Ⅳ型分离困难中转开腹,胆总管中下段缺失行胆肠吻合术,T管支撑引流术,术后半年拔除T管后,患者有反复发热症状,经保守治疗1年后症状不能完全缓解,再次手术行肝脏右后叶切除术及肝门部胆管成形+胆肠吻合内引流术。结论 Mirizzi综合征诊断困难,腹腔镜手术时易发生胆管损伤等并发症,术前ERCP有利于明确诊断,减少并发症;部分Ⅰ～Ⅱ型患者可以腹腔镜下完成手术;根据术中不同情况选择不同的手术方式,可收到良好的治疗效果。

Objective To explore the methods for diagnosing and treating Mirizzi syndrome in laparoscopic cholecystectomy（LC）,as well as the outcomes of the treatments.Methods From October 2003 to September 2010,22 patients with Mirizzi syndrome,which was detected during LC,were admitted to our hospital.We retrospectively analyzed the clinical data and summarized the diagnosis,management,and outcomes of the patients.Results According to Csendes Classification,13 of the patients were type Ⅰ,6 were type Ⅱ,2 were type Ⅲ,and 1 was type Ⅳ.LC was completed in 14 patients,who were all types Ⅰ or Ⅱ;the other 8 patients were converted to open surgery.Preoperative ERCP was carried out in 7 cases,none of them had injuries to the bile duct.Intraoperative injury to the bile duct occurred in 6 patients（end-to-end anastomosis of the bile duct in 2 cases and repair of the bile duct fistula in the other 4）.The case of type Ⅳ were converted to open surgery because of difficulties in separating the tissues.Cholangiojejunostomy followed by T-tube drainage was performed on this patient for the middle and lower bile duct defect.The T-tube was removed in six months after the treatment;the patient developed repeated episodes of fever,which was not relieved after 1-year conservative therapies,and thus received a second operation for resection of the right posterior lobe of the liver and hilar cholangioplasty＋ biliary intestinal drainage.Conclusions The diagnosis of Mirizzi syndrome is difficult.Biliary injury is apt to occur during LC,and thus preoperative ERCP is helpful to confirm the diagnosis and reduce surgical complications.LC can be completed in some of the patients with type Ⅰ or Ⅱ Mirizzi syndrome.The outcomes of the patients rely on appropriate surgical approaches which are selected according to what is detected during LC.