腹腔镜下经胆囊管切开取石与胆总管切开取石胆道一期缝合术的对比研究

Comparison of Transcyst with Trarsduct Incision in Laparoscopic Choledochotomy with Primary Ductal Closure

目的应用腹腔镜技术经胆囊管切开取石、胆道一期缝合与经胆总管切开取石、胆道一期缝合治疗肝外胆管结石，对比分析两种术式在胆漏发生等方面的优劣，探讨经胆囊管切开胆总管取石、胆道一期缝合治疗肝外胆管结石的可行性。方法2011年1月～2012年10月，应用腹腔镜微创手术治疗胆总管结石118例，其中适合行一期缝合的患者按手术顺序的奇偶分为经胆囊管切开胆总管取石、胆道一期缝合组（实验组）与经胆总管切开取石、胆道一期缝合组（对照组），每组59例。比较2组胆总管切开长度、胆道镜探查情况及残石率、一期缝合时间、胆漏发生率等。结果均在腹腔镜下顺利完成手术。实验组胆总管切开长度明显短于对照组[（8．2±2．2）mmvs．（13．8±2．9）mm，t=-11．772，P=0．000]。实验组胆道镜向肝总管探查失败率22％（13／59），1例发生胆总管末端残留结石；对照组胆道镜探查顺利，胆总管及肝总管内无残留结石。一期缝合时间实验组长于对照组[（25．5±7．2）min vs．（10．3±4．1）min，t=14．074，P=0．000]，但在总手术时间上2组差异无显著性[（85．5±20．9）minvs．（81．8±18．6）min，t=1．009，P=0．232）。实验组术后胆漏发生率明显低于对照组[3．4％（2／59）vs ．15．3％（9／59），x^2=4．912，P=0．027]；实验组术后引流量明显少于对照组[（20．7±5．4）ml vs．（50．2±20．6）ml，t=-10．640，P=0．000]。结论腹腔镜下经胆囊管切开取石一期缝合较胆总管切开取石胆道一期缝合更为安全、微创、可行。

Objective To compare the effect of primary duct closure transcyst or transduet incision on bile leakage during laparoseopic eholedochotomy and investigate the feasibility of transduct incision. Methods A total of 118 patients with common bile duct calculi underwent laparoseopic choledoehotomy with primary duct closure from January 2011 to October 2012. The patients were divided into two groups （59 in each group） by the order of parity number in operation. Patients in odd number were experimental group （transcyst）, while the even number patients were control group （transduct）. The length of common bile duct incision, the failure rate of choledochoseope exploration, the rate of residual stone, the time of primary closure, and the incidence of postoperative bile leakage were compared in the two groups. Results All surgeries were completed successfully under laparoseope. The bile duct incision length in experimental group was significantly shorter than that of the control group [ （8.2 ±2.2） mm vs. （13.8 ± 2.9） mm, t = - 11. 772, P = 0. 000 ]. In the experimental group, the failure rate of choledoehoseope exploration was 22% （13/59） , and there was 1 case of hepatic duct residual calculi. In the control group, choledochoseopc exploration was successful, and no residual calculi was found in the common bile duct. Primary closure took longer time in the experimental group than in the control group [ （25.5 ± 7.2） min vs. （10.3±＋4.1 ） min, t = 14. 074, P = 0. 000], while the total operative time of the two groups had no significant difference [（85.5 ±20.9） min vs. （81.8 ±18.6）rain, t = 1.009, P =0.232]. The rate of bile leakage in the experimental group was significantly lower than that in the control group [ 3.4% （2/59） vs. 15.3% （9/59）, x^2 = 4. 912, P = 0. 0271. Besides, the drainage volume in the experimental group was less than that in the control group [ （20.7± 5.4） ml vs. （50.2 ± 20. 6） ml, t = - 10. 640, P = 0. 000]. Conclusion Laparoscopic eholedochotomy with primary ductal closure via cystic duct incision is safer, more minimally invasive and more feasible than via common bile duct incision.