腹腔镜胆囊切除术中胆囊管切开探查的临床研究

Clinical study of cystic duct exploration during laparoscopic cholecystectomy

目的:探讨腹腔镜胆囊切除术(LC)中胆囊管切开探查的方法与技巧,进一步提高腹腔镜胆囊切除术的安全性与有效性。方法:回顾分析2017年4月至2019年2月为197例患者于LC术中切开胆囊管探查的临床资料,根据胆囊管切开方法分为胆囊管横向切开组(n=100例,横向组)与胆囊管T形切开探查组(n=97,T形组),记录两组术中胆囊与胆囊管的分离情况、失血量、胆囊管切开探查结果,比较分析两组胆囊管切开探查情况、手术时间、胃肠功能恢复时间、并发症发生率及住院时间等相关指标。结果:197例均在腹腔镜下完成胆囊管切开探查与胆囊切除术,术中均无胆管损伤等严重并发症发生。两组胆囊管探查阳性率差异无统计学意义(P>0.05);两组术中分别发生6例、5例胆囊动脉出血,差异无统计学意义(P>0.05);胆囊管表面出血分别为7例与8例,差异无统计学意义(P>0.05);两组手术时间、胃肠功能恢复时间、术中失血量、术后并发症发生率及术后住院时间差异均无统计学意义(P>0.05)。结论:预防与避免胆管损伤、胆囊管精细化分离解剖是胆囊管切开探查的基本前提,顺逆结合或逆行游离胆囊利于胆囊管全程显露及胆囊管切开探查;胆囊管横向切开探查与T形切开探查均是安全、有效的,既可处理胆囊管结石,又可有效预防胆囊管结石残留,其应用需依据术中胆囊管具体情况而定。

Objective:To explore the methods and techniques of cystic duct exploration during laparoscopic cholecystectomy(LC).Methods:Retrospective analysis was made on the clinical data of 197 patients who underwent cystic duct exploration during LC from Apr.2017 to Feb.2019.According to the different methods of cystic duct exploration,all patients were divided into the cystic duct transverse incision exploration group(transverse incision group,n=100) and cystic duct T-type incision exploration group(T-type incision group,n=97).Combined with surgery video,surgery record and other clinical data from the two groups,the results were compared about cystic duct exploration,operation time,gastrointestinal function recovery time,complication rate and hospital stay between the two groups.Results:LC and exploration of cystic duct were completed in all of 197 patients.There was no significant difference in the positive rate of cystic duct exploration between the two groups(P>0.05).In the transverse incision group and the T-type incision group,the cystic artery hemorrhage occurred in 6 cases and 5 cases(P>0.05),and the surface bleeding of the cystic duct occurred in 7 cases and 8 cases(P>0.05),respectively,there were no serious complications such as bile duct injury during operation.There was no significant difference in the mean operative time,the recovery time of bowel function,blood loss during surgery,the incidence of postoperative complications,or the postoperative hospital stay between transverse incision group and T-type incision group(P>0.05).Conclusions:Prevention and avoidance of bile duct injury,fine separation and anatomy of cystic duct are the basic premise of safe incision exploration of cystic duct.The combination of prograde-retrograde separation or retrograde separation gallbladder until confluence are beneficial to expose and explore cystic duct.Cystic duct transverse incision and cystic duct T-type incision are both safe and effective methods for cystic duct exploration.These operative methods can not only treat the cystic duct calculi,but also effectively prevent the residual stones in cystic duct.The application should base on the specific intraoperative conditions of the cystic duct.