肝内外胆管结石的微创治疗策略

Strategy of minimally invasive surgery for patients with intrahepatic and extrahepatic bile duct stones

肝内外胆管结石是一种常见、多发疾病,其传统的开腹手术近年来受到微创手术的挑战.本文通过文献检索,结合作者的实践经验,在全面总结肝内、外胆管结石的微创治疗现状基础上,探讨出一种可有效提高其微创治疗效果的策略:(1)对于肝内胆管结石:可根据指征选用腹腔镜肝切除、腹腔镜胆总管探查取石术(laparoscopic common bile duct exploration,LCBDE)、经皮经肝胆道镜取石术;(2)对于胆囊结石合并胆总管结石:可根据指征选用腹腔镜胆囊切除(laparoscopic cholecystectomy,LC)+经内镜十二指肠乳头括约肌切开(endoscopic sphincterotomy,EST)或经内镜乳头气囊扩张术(endoscopic papillary balloon dilatation,E P B D)、L C+经胆囊管胆总管探查取石术(laparoscopic transcystic common bile duct exploration,LTCBDE)、LC+LCBDE+T管引流或一期缝合术;(3)对于肝内合并肝外胆管结石,可根据指征选用腹腔镜肝切除、经肝断面胆管胆道镜取石、LCBDE、EST、经皮经肝胆道镜碎石术.根据上述策略,结合术者的技术和设备条件,合理选择微创治疗方法,对于提高肝内、外胆管结石的治疗效果具有重要意义.

Cholelithiasis is a common,frequently occurring disease.In recent years,traditional laparotomy is challenged by minimally invasive surgery.Through literature review combined with our practical experience based on the present situation of minimally invasive treatment of intrahepatic and extrahepatic bile duct stones,a strategy for improving the effectiveness of minimally invasive treatment is discussed as follows：（1） For intrahepatic bile duct stones,laparoscopic hepatectomy,laparoscopic common bile duct exploration（LCBDE）,or percutaneous transhepatic cholangioscopy can be chosen according to the indications;（2）For concomitant gallstones and common bile duct stones,laparoscopic cholecystectomy（LC） ＋ endoscopic sphincterotomy（EST） or endoscopic papillary balloon dilatation（EPBD）,LC ＋ laparoscopic transcystic common bile duct exploration（LTCBDE）,LC ＋ LCBDE ＋ T tube drainage or primary suture can be chosen according to the indications;（3） For concomitant intrahepatic and extrahepatic bile duct stones,laparoscopic liver resection,choledochoscopy through the hepatic duct orifice on the hepatectomy cross-section,LCBDE,EST,or percutaneous transhepatic cholangioscopic lithotripsy could be chosen according to the indications.Reasonable selection of minimally invasive treatments according to this strategy is of great significance to improve the therapeutic effect for intrahepatic and extrahepatic bile duct stones.