腹腔镜联合胆道镜治疗胆囊结石合并胆总管结石手术困难因素分析及临床对策

The difficult factors and their solution of laparoscopy combined with choledochoscopy for cholecystolithiasis and choledocholithiasis

目的:探讨腹腔镜联合胆道镜治疗胆囊结石合并胆总管结石的困难因素,并提出相应的临床对策。方法:回顾分析2013年9月至2018年10月为116例患者行腹腔镜胆囊切除(LC)联合腹腔镜胆总管探查(LCBDE)的临床资料,按手术时间、是否中转开腹、有无结石残留分组,应用单因素分析及多因素Logistic回归分析,探讨LC联合LCBDE手术困难的独立危险因素。结果:116例患者中容易组63例、困难组53例。单因素分析显示:胆囊大小、胆囊壁炎症严重程度、胆囊三角解剖关系显露情况、胆总管下段有无结石嵌顿及胆总管直径均是LC联合LCBDE手术难度较大的危险因素(P<0.05)。多因素Logistic回归结果显示,胆囊三角显露不清(OR=14.090,P<0.001)、胆囊壁化脓坏疽(OR=20.057,P=0.011)、胆总管下段结石嵌顿(OR=23.001,P=0.006)及胆总管直径≥12 mm(OR=3.950,P=0.008)是LC联合LCBDE手术困难的独立危险因素。结论:胆囊结石合并胆总管结石伴有胆囊三角显露不清、胆囊壁化脓坏疽、胆总管下段结石嵌顿、胆总管直径≥12 mm时,LC联合LCBDE的手术困难、危险性明显增加,临床应重视此类患者的术前评估及术中操作,以降低手术困难发生率。

Objective: To investigate the difficult factors and its solution of laparoscopy combined with choledochoscopy for cholecystolithiasis and choledocholithiasis. Methods: The clinical data of 116 patients who underwent laparoscopic cholecystectomy combined with laparoscopic common bile duct exploration from Sep.2013 to Oct.2018 were collected for retrospective analysis.They were divided in to two groups according to the operative time,intraoperative conversion to open surgery and residual calculi.Univariate analysis and multivariate logistic regression analysis was used to explore the independent risk factors of surgical difficulty. Results: Among the 116 cases,63 cases were divided into easy group and 53 cases were divided into difficult group.The univariate analysis showed that the gallbladder size,the severity of gallbladder inflammation,the operational exposure of Calot triangle,the existence of impacted stones in the lower part of common bile duct and the diameter of common bile duct were the risk factors affecting the difficulty of surgery ( P< 0.05).Multivariate logistic regression analysis showed that the unclear exposure of Calot triangle ( OR =14.090, P< 0.001),septic and gangrenous cholecystitis ( OR =20.057, P =0.011),the impacted calculi in the lower part of common bile duct ( OR =23.001, P = 0.006) and diameter of common bile duct greater than 12 mm ( OR =3.950, P =0.008) were the independent risk factors of surgical difficulty. Conclusions: If choledocholithiasis and cholecystolithiasis are accompanied by unclear exposure of Calot triangle,septic and gangrenous cholecystitis,impacted stones in the lower part of common bile duct or common bile duct diameter greater than 12 mm,the surgical difficulty and risk obviously increase,and the preoperative evaluation and intraoperative operation of these patients should be given adequate attention to reduce the incidence of difficult surgeries.