经剑突下孔直接取石法在腹腔镜胆总管切开取石术中的应用

Clinical effect of laparoscopic choledocholithotomy with direct stone removal through subxiphoid foramen

目的探讨经剑突下孔直接取石法在腹腔镜胆总管切开取石术中的应用效果,并总结手术经验。方法回顾性分析蚌埠市第一人民医院2014年11月—2018年4月86例胆总管结石患者的临床资料,其中男28例、女58例,年龄25~78(50.8±10.5)岁,均观察行腹腔镜手术,术中于胆总管切开后经剑突下孔直接取石。记录成功实施腹腔镜手术患者的手术时间、术中出血量、术后下床时间、术后排气时间、引流管拔除时间、术后住院时间、手术成功率及随访并发症,并总结技术经验。结果成功完成腹腔镜下手术81例,成功率94.2%(81/86),其中1例因末端结石嵌顿难以取出,后经胆道镜下碎石取出。其余5例中,1例因胆囊十二指肠漏中转开放手术,4例因胆囊炎急性发作后三角区纤维化难以分离而中转开腹。81例成功手术者:手术时间为(80.2±18.6)min,术中出血量为(20.0±3.0)mL,术后下床时间为(15.5±5.7)h,术后排气时间为(30.2±10.2)h,引流管拔除时间为术后(2.4±0.4)d,术后住院时间(10.4±2.6)d。术后4~6周拔除T管;随访6~12个月,平均8.5个月,无术后胆漏、胆道狭窄、再发胆管结石等并发症。结论经剑突下孔直接取石法使腹腔镜下胆总管切开取石术变得简单易行且安全,通过选择合适的患者,调整剑突下孔的位置、注意手术细节,改进手术流程,可减少了手术时间、创伤,并能取尽结石,获得满意的疗效。

Objective To explore the efficacy and surgical techniques of laparoscopic choledocholithotomy with direct stone removal through subxiphoid foramen.Methods The clinical data of 86 patients with choledocholithiasis who underwent laparoscopic choledocholithotomy through the subxiphoid foramen from November 2014 to April 2018 in Bengbu First People's Hospital were retrospectively analyzed.There were 28 males and 58 females aged 25-78(50.8±10.5)years.The operation time,intraoperative bleeding volume,time to get out of bed after operation,time to exhaust after operation,time to pull out drainage tube,hospital stay,postoperative complication and success rate of operation were observed according to the treatment.Results Laparoscopic surgery was successfully performed in 81 cases,with a success rate of 94.2%((81/86).One case was difficult to remove due to incarceration of terminal stones,and then was removed by choledochoscope.Among the other 5 cases,1 case was converted to open surgery because of gallbladder duodenal leakage,and 4 cases were converted to open surgery because of the difficulty of separating triangular fibrosis after acute cholecystitis attack.The operation time was(80.2±18.6)min,intraoperative bleeding volume was(20.0±3.0)mL.The postoperative time of getting out of bed was(15.5±5.7)h,postoperative exhaust time was(30.2±10.2)h,time to pull out drainage tube was(2.4±0.4)d,and the postoperative hospitalization time was(10.4±2.6)d.T-tube was removed 4-6 weeks after operation.Eighty-one cases were followed up for 6 to 12 months,with an average of 8.5 months.No complications such as bile leakage,biliary stricture and recurrence of bile duct stones occurred after operation.Conclusions It is a safe,effective and feasible microtrauma surgery for treating choledocholithiasis underwent laparoscopic choledocho lithotomy via subxiphoid foramen.By choosing the appropriate patient,adjusting the position of the hole under xiphoid process and adjusting the operation details and improving the operation procedure,the operation time and trauma are reduced,and the stones can be removed completely.