腹腔镜胆总管探查术治疗胆管结石临床研究

Clinical study on laparoscopic common bile duct exploration for bile duct calculi

目的探讨腹腔镜胆总管探查术(LCBDE)治疗胆管结石的安全性和疗效。方法回顾性分析2012年9月至2015年3月陕西省人民医院收治的236例胆管结石患者临床资料。患者均签署知情同意书,符合医学伦理学规定。其中男98例,女138例;年龄15~95岁,中位年龄58岁。采用四孔法行腹腔镜手术。于胆囊管与胆总管汇合处下方切开胆总管前壁0.5~1.5 cm,腹腔镜直视下胆道镜取出结石。取净结石后用4-0可吸收缝线一期缝合胆总管切口或放置T管引流。结果 233例患者成功施行LCBDE,中转开腹率1.3%(3/236),其中1例术中发现胆囊癌,中转开腹行胆囊癌根治术;另2例因肝门部胆管狭窄,开腹行肝肠吻合。经胆总管途径探查225例,经胆囊管途径探查8例;161例行胆总管一期缝合,72例放置T管。16例胆总管下端结石嵌顿或肝内胆管结石位置深在,经胆道镜下碎石后取净结石。手术时间中位数95(60~225)min,术中出血量60(20~250)ml,术后住院时间6.5(4.0~15.0)d。无围手术期死亡,术后并发症发生率6.9%(16/233),其中胆漏9例,残余结石3例,轻型胰腺炎3例,腹腔积液1例。随访10~40个月,患者无结石复发和胆道狭窄。结论 LCBDE创伤小、恢复快、并发症少,是一种安全、有效的治疗胆管结石的微创术式。

Objective To evaluate the safety and efficacy of laparoscopic common bile duct exploration （LCBDE） in the treatment of bile duct calculi. Methods Clinical data of 236 patients with bile duct calculi in Shaanxi Provincial People＇s Hospital between September 2012 and March 2015 were analyzed retrospectively. The informed consents of all patients were obtained and the local ethical committee approval was received. There were 98 males and 138 females, aged from 15-95 with a median of 58 years old. Laparoscopic surgery was performed via four-port approach. The anterior wall of common bile duct was cut in a length of 0.5 to 1.5 cm below the junction of cystic duct and common bile duct. Calculi were removed with a choledochoscope under laparoscope. After the calculi were removed completely, incision of the common bile duct was primarily sutured with 4-0 absorbable thread or a T tube was placed for drainage. Results LCBDE was performed successfully on 233 patients, with a rate of conversion to open laparotomy 1.3%（3/236）, including 1 case was converted to laparotomic radical cholecystectomy for gallbladder carcinoma, 2 cases receiving laparotomic hepaticojejunostomy for hilar bile duct stricture. 225 cases underwent common bile duct exploration, 8 cases underwent cystic duct exploration. 161 cases underwent primary suture of common bile duct, and 72 cases received placement of T tube. The calculi incarcerated in the lower end of common bile duct or deep located at intrahepatic bile duct in 16 cases were removed completely after lithotripsy under a choledochoscope. The median length of operation was 95（60-225） min, the intraoperative blood loss was 60（20-250） ml, and the postoperative length of stay was 6.5（4.0-15.0） d. No perioperative death was observed, and the incidence of postoperative complications was 6.9%（16/233）, including 9 cases of bile leakage, 3 cases of residual calculi, 3 cases of mild pancreatitis and 1 case of peritoneal effusion. The patients were followed up for 10-40 months, and no recurrent calculi or biliary stricture occurred. Conclusions LCBDE is a safe and effective minimally invasive surgical treatment for patients with bile duct calculi, which is characterized by less trauma, rapid recovery and less complications.