上腹部手术史患者行LCBDE的技术难点与对策

Technical difficulties and countermeasures for patients with history of upper abdominal surgery receive the LCBDE surgery

目的研究存在上腹部手术史患者行腹腔镜下胆总管探查术(Laparoscopic Common Bi Le Duct Exploration,LCBDE)的临床可行性及安全性,总结其技术难点与对策。方法回顾性分析2014年6月~2017年12月期间芜湖市第二人民医院收治的157例拟行LCBDE术患者的临床资料,根据入组患者是否合并上腹部手术史,分为A、B两组(即无上腹部手术史为A组,有上腹部手术史为B组),比较两组患者的相关临床指标;分析总结有上腹部手术史患者行LCBDE的技术难点及心得体会。结果入选A组患者130例(无上腹部手术史,n=130),入选B组(有上腹部手术史)患者共27例。比较A、B两组患者手术及术后疗效的相关指标,发现两组患者的手术时间、术后胃管留置比例、术后饮食恢复时间、术后引流管留置时间以及术后住院时间等指标之间差异有统计学意义(P<0.05);其余观察指标包括两组患者的腹腔镜中转开腹率、术中出血量、手术术式、术后24小时疼痛程度评分、术后自主下床活动时间、术后胆道结石残留率、非计划再手术比例等无明显统计学意义(P>0.05)。27例入选B组的患者,4例发生中转,手术成功率为85.19%(23/27),所有观察组患者术中、术后都未出现大出血、感染、损伤等严重并发症,均顺利恢复出院。结论存在上腹部手术史的患者行LCBDE术是安全、可行的,它的技术难点是手术入路的建立、腹腔粘连的分离以及胆管切开,选择合适的病例,掌握恰当的手术时机,重视术中精细操作及围手术期的管理,可以保证此类患者获得满意的治疗效果。

Objective To summarize the clinical feasibility and safety of Laparoscopic Common Bile Duct Exploration （LCBDE） in patients with upper abdominal surgery history, and summarize its technical difficulties and countermeasures. Methods The clinical data of 157 patients with LCBDE in Wuhu Second People＇s Hospital during the period of June 2014 and December 2017 were analyzed retrospectively. According to whether the patients with upper abdominal operation history, they were divided into two groups： group A and B （ with the history of upper abdominal surgery was group A, without the history of upper abdominal surgery was group B）, and the clinical indicators of the two groups were compared, in order to analyze and summarize the technical difficulties and countermeasures for patients with history of upper abdominal surgery receive the LCBDE surgery. Results 130 patients were enrolled in group A （ without history of abdominal surgery, n = 130）, and a total of 27 patients were enrolled in group B （ with the history of upper abdominal surgery）. Compare the related indexes of operation and postoperative curative effect in the two groups of A and B, and conclude that there was a significant difference between the two groups in operative time, postoperative indwelling gastric tube ratio, postoperative recovery time, postoperative drainage time and postoperative hospitalization time （P 〈 0.05）. While the other observation indexes included the conversion rate of laparoscopic surgery, the amount of bleeding, postoperative independent ambulation time, post-operative pain score of 24 hours, the proportion of non planned reoperation rate, residual bile duct stones after operation in two groups of patients was not statistically significant （ P 〉 0.05）. 4 patients in group B underwent conversion during laparoscopic surgery, the success rate of operation was 85.19% （23/27）. There were no serious bleeding, injury or infection occurred in all the patients. Conclusion LCBDE surgery in patients with the history of upper abdominal surgery is feasibile and safe. The technical difficulties are the establishment of surgical approach, the separation of abdominal adhesions, and the incision of the bile duct. We believe that choosing the right cases, mastering the right operation time, paying attention to fine operation and perioperative management can ensure that these patients achieve satisfactory therapeutic effect.