腹腔镜胆总管探查结合球囊导管扩张即时缝合胆总管切口的探讨

Study on the primary closure of bile duct incision of laparoscopic bile duct exploration and balloon dilatation catheter dilatation

目的探讨腹腔镜胆总管探查术中，结合球囊导管扩张治疗 Oddi括约肌和肝内胆管狭窄，行胆管切口即时缝合的适应证和并发症。方法采用腹腔镜胆总管探查取石，结合球囊导管行 Oddi括约肌或肝内胆管狭窄扩张术，效果满意，经胆道镜检查结石取净后，胆管切口用 4-0或 5-0可吸收缝线即时缝合，不放置胆道内外引流， Winslow孔附近常规放置腹腔多孔引流管观察渗漏情况。结果 42例中 41例获成功（结石取净、狭窄扩张满意及即时缝合术后无胆漏）。 8例肝管Ⅰ、Ⅱ级分支狭窄者经扩张，胆道镜先端可通过狭窄。 1例术后从腹腔引流管流出胆汁 30～ 150 ml/d，持续 4d后减至 20 ml/d,术后 6 d拔管， 8 d痊愈出院。术后 3个月门诊 B超检查发现 1例继发性胆总管结石患者，有胆管积气和胆管炎； 1例原发性肝胆管结石有左肝管残留结石。结论腹腔镜胆管探查术中结石取净后，对合适病例用斑马导丝引导耐高压球囊导管或抗划损球囊导管扩张 Oddi括约肌狭窄和肝内胆管狭窄，胆管切口采用可吸收缝线即时缝合，不放置胆道内外引流是较安全、可行的。

Objective To discuss the indications and complications of primary closure of bile duct incision in laparoscopic bile duct exploration and balloon dilatation catheter dilatation to treat the papillary stenosis and the intrahepatic bile duct stenosis. Methods A pospective study of 42 ptients of bile duct incision closure primary in laparoscopic bile duct exploration and balloon dilatation catheter dilatation, laparoscopic bile duct exploration and extraction of bile duct stones with choledochotomy was first adopted in order to clear the stones, then followed by the balloon dilatation catheter(explosive pressure reached 2020 kPa, used 505kPa) to dilate the papillary stenosis and the intrahepatic bile duct stenosis (CT-7542～ CT-75104) until the stenosis was released. Whether the primary closure of duct incision was selected or not, it was based on the situation of intraoperative choledochoscopic exploration, if it had been selected, the closure of bile duct incision would accepted by using absorbable suture 4-0 or 5-0, without placing bile duct drainage.It was routinely to place the drainage tube in the oriffice of the lesser omentum. Results 41 out of 42 patients had obtained successful duct clearance, the dilatation of the stenosis to reach the expected expansion and without bile leakage. One patient had bile leakage about 30-150 ml daily persisted for 4 days through cured conservatively. Conclusion Eventually it was safe and effective for some patients who had completed successful duct clearance and the dilatation of the stenosis to reach the expected expansion with the balloon dilatation catheter. They were adopted to the primary closure of duct incision using absorbable suture and did not need to place bile duct drainage.