腹腔镜下胆道镜联合液电碎石经胆囊管治疗胆总管巨大结石的临床分析

Clinical analysis of laparoscopy and choledochoscopy combined with electrohydraulic lithotripsy in the treatment of large common bile duct stones

目的：探讨腹腔镜下胆道镜联合液电碎石经胆囊管治疗胆道巨大结石的疗效。方法：回顾分析2005年1月至2013年11月84例因梗阻性黄疸、胆总管巨大结石行腹腔镜下胆道镜联合液电碎石经胆囊管取石患者的临床资料。结果：80例成功完成手术。1例因胆道出血中转开腹行胆总管切开止血、取石＋T管引流术；1例患者怀疑胆道下段肿瘤中转开腹探查并行胰十二指肠切除术，术中冰冻病理证实为胆管癌；1例患者经胆囊管取石毕发现乳头下端狭窄，术中行内镜逆行胰胆管造影及乳头肌切开后胆汁流出通畅；1例患者因Mirizzi综合征导致胆囊三角区粘连紧密从而中转开腹行胆总管切开取石、T管引流术。术后均无出血、胆漏、胆总管损伤等并发症发生，术后住院7—11d。结论：腹腔镜下胆道镜联合液电碎石经胆囊管取石术治疗胆总管巨大结石安全、可靠，手术微创，结石清除率高，并发症少；对于胆囊管粗短直、入口较大的患者，可直接置入胆道镜探查取石，损伤小，优点突出，值得临床应用。

Objective： To discuss the efficacy of laparoscopy and choledochoscopy combined with electrohydraulic lithotripsy in the treatment of large common bile duct stones. Methods ： Retrospective analysis was made on the clinical data of 84 patients with obstructive jaundice and large common bile duct stones, who were treated by laparoscopy and choledochoscopy combined with electro- hydraulic lithotripsy from Jan. 2005 to Nov. 2013. Results：Laparoscopy was successfully carried out in 80 cases, 1 case was converted to open choledocholithotomy,hemostasis and T-tube drainage because of hemobilia. 1 case was converted to open exploration and pancreatoduodenectomy because of doubtful lower biliary tumor,cbolangiocareinoma was confirmed according to intraoperative frozen pathology;1 case was confirmed lower papillary stenosis after transcystic duct calculi removal, endoscopic retrograde cholangiopancreatography and sphincterotomy was performed immediately and the bile flowed smoothly ; and another case was converted to open choledocholithotomy and T-tube drainage because of close adhesion at Calot triangle caused by Mirizzi syndrome. There were no postoperative complications such as hemorrhage, bile leakage or common bile duct injury, postoperative hospital stay was 7-11 d. Conclusions：Laparoscopy and choledochoscopy combined with electrohydraulic lithotripsy in the treatment of large common bile duct stones is minimally invasive, safe and reliable, with high calculi removal rate and few complications. For patients with wide, short and straight cystic duct with large entrance, choledochoscope can be directly inserted to remove calculi with few trauma. The merits of this procedure are outstanding, which is worthy to be popularized.