腹腔镜胆道镜联合体内冲击波碎石仪治疗胆管嵌顿性结石(附50例报告)

Laparoscopy,choledochoscopy and shock-wave lithotripsy in vivo for impacted bile calculi:with a report of 50 cases

目的：探讨腹腔镜、胆道镜下体内冲击波碎石术治疗嵌顿性胆管结石的临床疗效及应用价值。方法：回顾分析2009年1月至2013年6月为50例胆管结石嵌顿患者行腹腔镜、胆道镜下冲击波碎石术的临床资料。结果：49例成功完成腹腔镜手术，1例术中因胆囊及胆总管周围组织粘连严重中转开腹。手术时间75～160min，平均（105±15）min；术中出血量30～120ml，平均（60±15）ml。术后第1天患者均可下床活动。术后平均胃肠功能恢复时间（2．0±1．0）d，术后住院3—12d，平均（6±3）d。1例患者术后第9天活动时不慎将T管拔出约3cm，经保守治疗痊愈。术后随访6个月一3年，未发生胆管狭窄等严重并发症。结论：联合应用体内冲击波碎石可提高腹腔镜下胆管结石尤其嵌顿性难取性结石的清除率，降低因取石困难被迫中转开腹的几率，手术安全、可行。

Objective： To explore the therapeutic effects and application value of shock-wave lithotripsy in vivo for bile impact- ed calculi via laparoscopie choledochoseopy. Methods ：The clinical data of 50 patients who suffered from bile impacted calculi and un- derwent laparoscopic choledochoseopy and shock-wave lithotripsy from Jan. 2009 to Jun. 2013 were retrospectively analyzed. Results： Laparoscopic operation was successfully performed for 49 patients ,while 1 patient was converted to laparotomy because of severe adhe- sion around the gallbladder and common bile duct. All calculi were removed completely from the 50 patients in one session without lead- ing to injury to the bile duct. No residual calculi were found by T-tube cholangiography, the extraction rate of bile duct calculi was 100%. The mean operative time was （ 105 ± 15 ） min （ range, 75-160 min）. The mean blood loss was （ 60 ± 15 ） ml （ range, 30- 120 ml）. Ambulation was on the first postoperative day. The mean time of postoperative gastrointestinal function recovery was （2.0 ± 1.0 ） d. The mean postoperative hospital stay was （6 ±3 ） d （ range, 3-12 d）. One case of unexpected sliding out of T-tube （ about 3 cm） happened and was solved without operation. All patients were followed up for 6 months-3 years, and during that period no serious complications such as stenosis of bile duct occurred. Conclusions ： Shock-wave lithotripsy in vivo combined with laparoscopic choledo- choscopy is a safe and feasible way for impacted bile calculi, which can raise the rate of clearance and lessen the chance of conversion to laparotomy,this technique should be extended by laparoscopic experts.