腹腔镜肝切除术中胆管损伤特点及防治策略

Characteristics and prevention strategies of bile duct injury during laparoscopic hepatectomy

腹腔镜肝切除术中胆管损伤的部位多为左、右肝管或以上的肝叶(段)胆管,临床表现为胆管狭窄、梗阻,胆漏及胆道出血等,其病情复杂、处理困难、后果严重。常见原因为切割闭合器使用不当、围肝门区病变肝切除操作不当、重要管道结构误判及肝断面偏移等。防范措施包括术前精确影像评估、正确选择使用切割闭合器、镜下精细操作及断面重要解剖结构的识别和确认等。严密的术后监测管理可尽早发现腹腔镜肝切除术中未能即时发现的胆管损伤,并根据损伤的部位、程度以及是否合并血管损伤等选择介入、再次手术等确定性治疗。

The most vulnerable part of the bile duct injury in the laparoscopic hepatectomy is the left, right hepatic duct or above hepatic lobe （segment） bile duct. The clinical manifestations are biliary stricture, obstruction, bile leakage and biliary bleeding, which are complicated, difficult to deal with, and have serious consequences. The common causes are improper use of the endostapler device, improper operation of hepatectomy for perihilar lesions, misjudgment of important bile duct structures and deviation of liver parenchymal transection plane. Preventive measures include accurate preoperative imaging assessment, correct usage of endostapier devices, fine laparoscopic manipulation, and identification and confirmation of important anatomical structures on the cross-section. Strict postoperative monitoring can find bile duct injury failure to detect during laparoscopic hepatectomy, and select interventional or reoperation treatment according to the location and degree of injury, and whether or not the vascular injury is combined.