腹腔镜胆囊切除术中肝外胆管变异的辨别与处理

Identification and treatment of variation of extrahepatic bile duct in laparoscopic cholecystectomy

目的探讨腹腔镜下胆囊切除术(LC)中肝外胆管变异的辨别及治疗方法,以减少胆道损伤的发生。方法回顾性分析2012年1月-2014年1月在武汉市蔡甸区人民医院行LC且术中发现肝外胆管结构变异的60例患者相关临床资料,总结术中及术后情况。结果术中发现胆囊管变异32例,胆囊管汇入肝外胆管位置异常20例,胆囊管与肝总管共一侧壁再汇入胆总管2例,胆囊床迷走胆管2例以及副肝管4例。顺利完成LC患者51例,成功率85%;中转开腹9例,中转率15%。所有患者均顺利完成手术,有2例发生术后并发症,其中1例存在胆管残留结石,另1例LC术后1周发生胆汁渗漏,再次手术后恢复。所有患者均痊愈出院,未出现腹腔内出血、感染及肠道损伤等严重并发症。结论掌握肝外胆管结构变异,术中细致分离解剖胆囊三角区,辨别肝外胆管变异的种类,针对性地给予合适的操作方法是LC的关键,可明显降低胆道损伤的发生率。

Objective To investigate the identification and treatment of variation of extrahepatic bile duct in laparoscopic cholecystectomy（ LC）,and to reduce the occurrence of bile duct injury. Methods This study included 60 patients who received LC in the People＇s Hospital of Caidian District in Wuhan and had structural variation of extrahepatic bile duct found during the operation from January 2012 to January2014. The clinical data were retrospectively analyzed,and the intraoperative and postoperative conditions were summarized. Results During operation,cystic duct variation was found in 32 cases,abnormal position of the point where the cystic duct joins the extrahepatic bile duct in 20 cases,the cystic duct and the common hepatic duct having the common wall before joining the common bile duct in 2 cases,aberrant bile duct in the gallbladder bed in 2 cases,and accessory hepatic duct in 4 cases. Fifty- one patients（ 85%） successfully underwent LC; 9 patients（ 15%） were converted to open surgery. All patients finished surgery successfully. There were 2 cases of postoperative complications; one patient developed residual stones in the bile duct,and bile leakage occurred in the other patient at one week after LC,who recovered after reoperation. All patients were cured and discharged,without severe complications such as intraperitoneal hemorrhage,infection,and intestinal injury. Conclusion Identifying the structural variation of extrahepatic bile duct,dissecting the Calot＇s triangle meticulously,and determining the type of variation of extrahepatic bile duct play important roles in LC and significantly reduce the incidence of bile duct injury.