基层医院腹腔镜胆囊切除术中、术后胆漏的防治

Prevention and treatment of bile leakage during and after laparoscopic cholecystectomy in primary hospital

目的:探讨腹腔镜胆囊切除术(LC)术中、术后胆漏的诊断、治疗及预防方法。方法:回顾分析2009年7月至2017年5月于LC术中、术后出现胆漏的7例患者的临床资料。结果:7例患者术中发现4例,术后2~7 d确诊3例。LC开展早期出现1例致死性胆漏患者,原因不明;钛夹夹闭不全及脱落致胆囊管残端漏2例,Luschka管漏1例,肝内胆管漏1例,肝总管壁损伤1例,左右肝管汇合部以上横断伤1例,经过术中、术后妥善治疗均痊愈出院,经术后3个月、6个月、1年、2年随访,无腹腔继发感染、胆道狭窄等并发症发生。结论:LC术中、术后出现胆漏的原因主要有胆道解剖变异、局部炎症、胆囊管残端钛夹脱落、电灼伤、腹腔镜术中视觉感知错觉、胆囊过度牵拉等。术中尽可能避免胆道损伤,出现胆漏应及时发现,进行规范、个体化处理,必要时转有经验的上级医院治疗。

Objective:To investigate the diagnosis,treatment and prevention of bile leakage during and after laparoscopic cholecystectomy.Methods:A retrospective analysis was performed on the clinical data of 7 patients with bile leakage during and after laparoscopic cholecystectomy from Jul.2009 to May 2017.Results:Among the 7 patients,4 cases of bile leakage were found during operation and 3 cases of bile leakage were diagnosed 2-7 days after operation.In the early stage of laparoscopic cholecystectomy,there was a case of fatal bile leakage with unknown reason.For the remaining 6 patients with bile leakage,2 cases of cystic duct stump leakage were caused by incomplete clipping of titanium clip,one was Luschka duct leakage,one was intrahepatic biliary duct leakage,one was common hepatic duct wall injury,another one was complete injury above the junction of left and right hepatic duct.Patients were cured and discharged after the proper treatment during and after operation.After the regular follow-up at 3,6,12 and 24 months after the procedure,there was no secondary infection in the abdominal cavity,and no complications such as biliary strictures.Conclusions:Many reasons count for bile leakage during and after laparoscopic cholecystectomy,such as anatomical variations of biliary tract,local inflammation,titanium clip detachment from cystic duct stump,electric burn,visual perception illusion during laparoscopic surgery,excessive traction of gallbladder,etc.Surgeons should avoid the bile tract injury,be cautious of bile leakage and perform standardized and individualized treatment in time.If necessary,the patient should be transferred to a superior hospital for further treatment.