腹腔镜下肝门暴露技术在小儿Ⅲ型胆道闭锁治疗中的应用研究

Application of laparoscopic hepatic portal exposure in children with type Ⅲ biliary atresia

目的探讨肝门暴露技术在腹腔镜下手术治疗小儿Ⅲ型胆道闭锁中的应用价值。方法选择淮安市妇女儿童医院2013年6月至2017年10月收治的Ⅲ型胆道闭锁患儿30例为研究对象,患儿均行腹腔镜下肝门肠吻合手术。充分应用肝门暴露技术,悬吊肝圆韧带、胆囊残端组织及胆囊颈部,充分游离肝门纤维块,游离门静脉左右分支及肝左右动脉,用两根弹性牵拉带环绕门静脉左右支及肝左右动脉,牵拉弹性牵拉带暴露肝门,切除肝门纤维块,完成肝门肠吻合手术。其中20例肝脏增大明显,行腹腔镜下肝方叶部分切除术。结果该组30例患儿中,28例在腹腔镜下顺利完成肝门肠吻合手术,2例中转右上腹小切口手术。无手术死亡病例。腹腔镜手术时间210~280min。术中出血量少,无术中输血者,无手术相关的特殊并发症。1例术后1周死于肺炎、呼吸衰竭,2例失去随访。25例获得3~51个月(平均22.4个月)随访,3例分别于术后10、16、35个月死于肝功能衰竭。19例黄疸完全清除。3例术后黄疸指数明显下降。结论腹腔镜下充分应用肝门暴露技术,可助顺利完成肝门肠吻合术,降低腹腔镜手术中转率,提高手术效果。

Objective To explore the clinical value of portal exposure in laparoscopic treatment of children with typeⅢbiliary atresia(BA).MethodsFrom June 2013 to October 2017,30 infants with typeⅢBA who treated with laparoscopic portoenterostomy in Huai'an Women and Children's Hospital were selected.A percutaneous suture was used to snare the round ligament and retract the liver,other percutaneous stay sutures were then introduced and fundus and neck of gallbladder were sutured to elevate the liver to expose the portal hepatis.The fibro cord and hepatic vessels were mobilized,and then two rubber bands were put around the left and right portal veins and hepatic arteries.The portal hepatis was exposed by laterally stretching the two elastic rubber bands.The fibro cord was removed and then laparoscopic portoenterostomy was accomplished.In 20 cases,the liver was enlarged,part of hepatic lobus quadratus was removed laparoscopiclly for exposure of the portal hepatis.ResultsThere were 30 cases in this group,2 cases were converted to open surgery by a micro transverse incision.There was no surgical death.Time of laparoscopic procedure varied from 210 to 280 min.All cases survived the surgery without any intraoperative complications.Blood loss during operation was minimal,without necessity for blood transfusion.One case died of respiratory failure one week after surgery.Two cases were lost follow-up.Twenty-five cases were followed up for 3~51 months(mean 22.4 months).Three cases died because of repeated cholangitis and liver failure at 10,16,35 months postoperatively.Nineteen patients'total bilirubin had dropped to normal,three others'bilirubin levels dropped significantly after surgery.ConclusionThe technique of laparoscopic hepatic porta exposure can help to complete hepatic portoenterostomy successfully,reduce the conversion rate of laparoscopic surgery,and improve the surgical effect.