3D与2D腹腔镜手术治疗TodaniI型胆总管囊状扩张症的疗效分析

Clinical efficacy of three.dimensional and two-dimensional laparoscopic surgeries in the treatment of Todanitype I choledochal cyst

目的探讨3D与2D腹腔镜手术治疗TodaniI型胆总管囊状扩张症的临床疗效。方法采用回顾性队列研究方法。收集2013年1月至2016年1月湖南省人民医院收治的59例TodaniI型胆总管囊状扩张症患者的临床资料。2013年1月至2014年6月采用2D腹腔镜手术治疗30例，设为2D腹腔镜组；2014年7月至2016年1月采用3D腹腔镜手术治疗29例，设为3D腹腔镜组。2D腹腔镜组和3D腹腔镜组Troear放置及手术过程相同，手术方式完全遵循TodaniI型胆管囊状扩张症治疗原则。观察指标：（1）手术情况：中转开腹情况、手术时间、术中出血量。（2）术后情况：术后并发症。（3）随访情况。采用门诊或电话随访，了解患者术后恢复情况，随访时间截至2016年4月30日。偏态分布的计量资料以M（范围）表示，行Mann-WhitneyU检验；计数资料比较采用Fisher确切概率法。结果（1）手术情况：两组患者均行腹腔镜下胆总管囊肿切除＋肝总管空肠Roux-en-Y吻合术。2D腹腔镜组中，2例中转开腹，3D腹腔镜组均顺利完成，无中转开腹。2D腹腔镜组和3D腹腔镜组患者中转开腹率分别为6．7％（2／30）和0，两组患者比较，差异无统计学意义（P〉0．05）。2D腹腔镜组和3D腹腔镜组患者手术时间分别为285min（240～390min）和190min（140-215min），两组患者比较，差异有统计学意义（U=40．0，P〈0．05）。2D腹腔镜组和3D腹腔镜组患者术中出血量分别为50mL（10～300mL）和45mL（20～250mL），两组患者比较，差异无统计学意义（U=1018．5，P〉0．05）。（2）术后情况：2D腹腔镜组和3D腹腔镜组患者术后恢复顺利，无Clavien-Dindo分级≥Ⅲ级严重并发症发生。其中2D腹腔镜组术后出现胆汁漏4例（Clavien．Dindo分级Ⅱ级），术后上消化道出血1例（Clavien-Dindo分级Ⅱ级）。3D腹腔镜组术后出现胆汁漏1例（Clavien-Dindo分级Ⅱ级），术后上消化道出血1例（Clavien-Dindo分级Ⅱ级），两组患者比较，差异均无统计学意义（P〉0．05）。2D腹腔镜组和3D腹腔镜组患者总体术后并发症发生率分别为16．7％（5／30）和10．3％（3／29），两组患者比较，差异无统计学意义（P〉0．05）。2D腹腔镜组和3D腹腔镜组发生并发症的患者均经保守治疗痊愈。（3）随访情况：59例患者均获得随访，随访时间为5～36个月。患者恢复良好，无反流性胆管炎和肝肠吻合口狭窄发生，无再次手术治疗者。结论3D与2D腹腔镜手术治疗TodaniI型胆总管囊状扩张症均安全有效，与2D腹腔镜手术比较，3D腹腔镜手术明显缩短手术时间，亦不增加并发症发生。

situations： conversion to open surgery, operation time, volume of intraoperative blood loss, （2） postoperative situations： postoperative complications, （3） follow-up. Patients were followed up by outpatient examination or telephone interview to detect postoperative recovery up to April 30, 2016. Measurement data with skewed distribution were presented as M （range） and analyzed using the Mann-Whitney U test. Count data were compared by Fisher exact probability. Results （ 1 ） Surgical situations： patients in the 2 groups underwent laparoscopic choledochal cystectomy ＋ Roux-en-Y hepaticojejunostomy. Two patients in the 2D group received conversion to open surgery and patients in the 3D group received the successful surgery without conversion to open surgery. Rate of conversion to open surgery in the 2D and 3D groups were 6. 7% （2/30） and O, respectively, with no statistically significant difference （P 〉 O. 05 ）. Operation time in the 2D and 3D groups were 285 minutes （range, 240-390 minutes） and 190 minutes （range, 140-215 minutes）, with a statistically significant difference （U = 40. 0, P 〈 O. 05）. Volume of intraoperative blood loss in the 2D and 3D groups were 50 mL （range, 10- 300mL） and 45 mL （range, 20-250 mL）, with no statistically significant difference （U = 1 018. 5, P 〉 O. 05 ）. （2） Postoperative situations ： patients in the 2 groups had good recovery, without occurrence of severe complications in Clavien-Dindo≥Ⅲ stage. Four and 1 patients in the 2D and 3D groups were complicated with bile leakage （in 11 stage of Clavien-Dindo） and 1 and 1 were complicated with upper gastrointestinal hemorrhage （ in Ⅱ stage of Clavien-Dindo）, respectively, with no statistically significant difference （P 〉 0. 05 ）. Overall incidence of complications in the 2D and 3 D groups were 16.7% （5/30） and 10.3 % （ 3/29）, with no statistically significant difference （P 〉 O. 05）. All the patients were cured by conservative treatment. （3） Follow-up： 59 patients were followed up h,r 5- 36 months, with good recovery and without occurrence of reflux cholangitis, hepatic and intestinal anastomosis stenosis and reoperation. Conclusions 3D and 2D laparoscopic surgeries are safe and effective for Todani type I choledochal cyst. Compared with 2D laparoscopic surgery, 3D laparoscopic surgery can reduce the operation time and not increase the complications, and it should be discreetly promoted based on the experiences of surgeons.