右肝前叶下段胆管异位与医源性近段胆管损伤修复八例

Ectopic right anterior inferior segmental bile duct and iatrogenic proximal bile duct injury:report of eight patients

目的总结右肝前叶下段胆管汇入胆囊管行腹腔镜胆囊切除时致近段胆管损伤的临床经验及处理策略。方法采用横断面研究方法,分析2003年3月至2019年1月湖南省人民医院收治的8例右肝前叶下段汇入胆囊管,胆囊切除时致近段胆管损伤患者的临床资料。结果全组8例患者术前CT、磁共振、腹部彩超结果均诊断为结石性胆囊炎,并未提示胆管变异。6例腹腔镜胆囊切除术(LC)术后因腹痛、胆汁性腹膜炎而再度开腹,施夹心T管引流。另外2例LC术中发现右肝前叶胆管异位开口汇入胆囊管,其中1例中转开腹作保留胆囊管次全切除胆囊、胆总管T管引流,另1例继续腹腔镜下保留胆囊管次全切除胆囊,放置胆总管T管引流。术后中位随访3.4年,效果满意。结论胆管变异是腹腔镜胆囊切除术中致医源性近段胆管损伤的主要原因。术前仔细阅片,术中对胆囊三角解剖结构精准辨别,不可盲目切断,严格做到"辨、切、辨"三字程序,以降低腹腔镜胆囊切除术后胆道损伤并发症的发生。

Objective To summarize our clinical experience and management of an anomalous proximal bile duct joining the cystic duct in laparoscopic cholecystectomy(LC).Methods A retrospective study was conducted on 8 patients who had an anomalous right anterior bile duct joining the cystic duct who were treated at the Hunan Provincial People's Hospital from March 2003 to January 2019.Results All the 8 patients were diagnosed to have gallstones cholecystitis on preoperative CT,MRI and abdominal ultrasound.There were no suggestions of an anomalous bile duct.A total of 6 patients underwent reoperation after LC due to abdominal pain and biliary peritonitis.These 6 patients were treated with drainage and T-tube insertion.In the other 2 patients,the anomalous bile duct opening which joined the cystic duct were detected during LC.There was one patient converted to open laparotomy with preservation of the cystic duct and underwent common bile duct T-tube drainage.The other patients continued with laparoscopic surgery.The cystic duct was partially resected with removal of gallbladder,followed by common bile duct drainage.The average follow-up period was 3.4 years and the results were satisfactory.Conclusions Biliary duct anomaly is the main cause of iatrogenic proximal bile duct injury during laparoscopic cholecystectomy.It is not uncommon to have the anomaly of insertion of right anterior segmental bile duct to the cystic duct.To avoid iatrogenic biliary tract injury,careful preoperative study of X-ray films,accurate identification of the intraoperative gallbladder triangle anatomical structures.Strict adherence to carry out the three-word procedure of"discrimination,cut,identify"will help to reduce the incidence of biliary tract complications in laparoscopic cholecystectomy.