腹腔镜胆总管囊肿术后再手术原因分析及处理

Causes and treatment of reoperation after laparoscopic cyst excision of choledochal cyst

目的探讨分析腹腔镜胆总管囊肿切除、肝总管空肠Roux-en-Y吻合术后再手术的原因及术式的选择。方法回顾性分析2012年3月至2016年10月，经腹腔镜行先天性胆总管囊肿根治术245例的临床资料。其中，男42例，女203例；囊肿型209例，梭形36例。结果243例患儿在腹腔镜下成功完成手术，2例中转开腹。术后再次手术9例。其中1例术后大出血，剖腹探查见出血部位为囊肿剥离面渗血，予以缝合剥离面后出血止；2例吻合口瘘，1例用肾盂造瘘管行腹壁穿刺引流术，引流3周后自愈，1例因弥漫性腹膜炎无法局限行开腹探查，肝管空肠再次吻合术；4例吻合口狭窄，其中1例为术后2周即出现梗阻性黄疸，再次手术，3例为术后门诊随访患儿，出现肝功能异常，GPT, r-GT持续升高，MRCP提示肝总管扩张伴信号中断，其中2例无梗阻性黄疸表现，1例有梗阻性黄疸，都再次腹腔镜下行胆肠吻合术，术后肝功能逐渐恢复正常，黄疸症状消失；2例腹腔包裹性积液，1例为膈下包裹性积液，1例为肝周包裹性积液，都予行腹壁穿刺引流，引流液非胆汁，为渗出液，引流4 d后拔出引流管，恢复良好；该9例患儿经再次手术，最终都治愈。结论腹腔镜行先天性胆总管囊肿切除肝总管空肠Roux-en-Y吻合术是复杂的高风险手术，再手术需要术者丰富的经验进行及时判断和恰当的处理，再次在腹腔镜下进行胆道重建也是可行的。

ObjectiveTo explore the causes of reoperation for laparoscopic total cyst excision with Roux-en-Y hepatoenterostomy for choledochal cyst in children and the choice of surgical procedure.MethodsRetrospective analyses were performed for 245 cases of laparoscopic total cyst excision with Roux-en-Y hepatoenterostomy choledochal cyst from March 2012 to October 2016.There were 42 males and 203 females.And the clinical types were cystic （n=209） and fusiform （n=36）.ResultsLaparoscopic procedure was completed successfully for 243 cases. Two cases were converted into open laparotomy due to portal venous hemorrhage and air embolism. Reoperation was performed for hemorrhage （n=1）, bile leakage （n=2）, anastomotic stenosis （n=4） and gallbladder fossa or subphrenic encapsulated fluid （n=2）. And exploratory laparotomy was performed for 1 hemorrhagic case. Intraoperative hemorrhage occurred from cyst surface. One case of bile leakage was cured completely after puncture drainage for encapsulated fluid while another get laparotomy for rehepatoenterostomy due to diffuse peritonitis. Laparoscopic rehepatoenterostomy for anastomotic stenosis were performed for 4 cases. Of which 1 case was performed 2 weeks after surgery due to obstructive jaundice. 3 cases were found with abnormal liver function; GPT and r-GT continued increasing or MRCP showed hepatic duct signal interruption. Among them, 2 cases had obstructive jaundice while another case without obstructive jaundice. Abdominal puncture drainage was performed for two encapsulated fluid cases including gallbladder fossa encapsulated fluid （n=1） and subphrenic encapsulated fluid （n=1）. Drainage tube was removed after 4 days. All 9 cases were cured after reoperation. ConclusionsLaparoscopic total cyst excision with Roux-en-Y hepatoenterostomy for choledochal cyst is a complex and high-risk procedure so that re-operation requires timely operator judgments and appropriate treatments. Laparoscopic rehepatoenterostomy is feasible.