腹腔镜下经胆囊管胆道探查取石术70例及术后胆漏的防治

Prevention and Treatment of Bile Leakage After Laparoscopic Transcystic Common Bile Duct Exploration: Report of 70 Cases

目的：探讨腹腔镜下经胆囊管胆道探查术（ laparoscopic transcystic common bile duct exploration ，LTCBDE）的经验及术后胆漏的原因及防治。方法2012年12月～2014年12月70例胆囊结石合并胆总管结石行LTCBDE：常规四孔法，解剖胆囊三角（ Calot三角），充分游离并结扎胆囊管，钳夹切断胆囊动脉，暂不切断胆囊管，牵引胆囊管，沿胆囊管纵轴切开胆囊管前壁0．5～0．8 cm，局部扩张胆囊管后置入胆道镜进行胆道探查，直至取净结石，最后在距胆总管3～5 mm处用可吸收线缝合结扎胆囊管，必要时在其远端生物夹夹闭，并在适当部位切断胆囊管，其他操作同LC。结果70例均成功完成LTCBDE，术中发现胆囊管残端缝合处胆漏1例，可吸收线缝合加固和生物夹夹闭处理后未再发生。手术时间60～155 min，（114．5±19．3）min；术中出血量10～80 ml，（23．7±12．5）ml。均放置腹腔引流管，66例术后5～9 d拔除，4例因术后发生胆漏，术后12～22 d拔除。术后住院时间7～24 d，（12．3±4．3）d；住院总费用（29143．1±2358．5）元。术后胆漏4例，其中2例保守治疗，保持腹腔管引流通畅；2例行ENBD，均痊愈出院。70例随访6～12个月，恢复良好，无结石复发，结石清除率达100％，无胆管炎、胆道狭窄等并发症发生。结论 LTCBDE手术难度大，对术者要求高，只有严格把握LTCBDE适应证，了解胆漏原因并积极进行防治，减少胆漏发生，降低胆漏风险，最大限度发挥LTCBDE的优势。

Objective To analyze the causes and to explore the prevention and management of bile leakage after laparoscopic transcystic common bile duct exploration （ LTCBDE ） for extrahepatic bile duct stones . Methods A total of 70 cases of LTCBDE performed from December 2012 to December 2014 in this department were retrospectively studied .The operation was conducted with conventional four-port method.The Calot triangle was dissected and the cystic duct was ligated .After the cut-off of the gallbladder artery, the anterior wall of the cystic duct was opened for 0.5 -0.8 cm along the longitudinal axis .Following local dilation, a choledochoscope was introduced to remove the stones thoroughly .Finally the incision was sutured with absorbable threads at 3-5 mm from the common bile duct , and the cystic duct was cut off .Distal closure with biological clips was required when necessary .The other performance was same as the laparoscopic cholecystectomy . Results All the 70 patients successfully underwent LTCBDE .During the operation, bile leakage at cystic stump was found in 1 case, and absorbable suture and biological clip closure were utilized .The operation time was 60-155 min, and the intraoperative blood loss was 10-80 ml.Peritoneal drainage tube placement was given in all the patients, which was removed after 5 -9 days in 66 cases and 12 -22 days in 4 cases due to postoperative bile leakage .The postoperative hospitalization was 7-12 days （mean, 12.3 ±4.3 days）, and the average hospitalization cost was （29 143.1 ±2358.5） yuan.Postoperative bile leakage happened in 4 cases, which were cured with conservative treatment in 2 cases and with ENBD in 2 cases.The follow-up period was 6-12 months.The stone clearance rate was 100%.No bile duct stricture or infection was found . Conclusion The bile leakage can be prevented to the utmost provided the indications of LTCBDE are strictly followed and the causes of leakage are fully understood .