腹腔镜肝切除术治疗肝内胆管结石中转开腹的原因分析及预防

Causes and prevention of conversion to laparotomy in treatment of intrahepatic bile duct stones by laparoscopic hepatectomy

目的探讨腹腔镜肝切除术治疗肝内胆管结石中转开腹的原因以及预防措施。方法回顾性分析2015年1月至2020年8月浙江省人民医院收治的165例因肝内胆管结石行腹腔镜肝切除术,其中15例中转开腹患者的临床资料。结果?本组资料中转开腹率为9.1%(15/165),其中男6例,女9例,年龄34~75岁,中位年龄57岁;肝功能Child-Pugh分级为A/B,其中合并高血压1例,糖尿病1例;既往有腹部手术史9例。平均手术时间(245.7±55.3)min,术中平均出血量(383.3±321.5)mL。中转开腹原因包括:腹腔内严重粘连9例,肝脏明显转位2例,术中出血止血困难2例,右肝管狭窄2例。术后并发症:腹腔感染2例,胸腔积液4例,腹腔感染合并胆道感染1例,胸腔积液合并胆道感染1例;所有患者均采用保守治疗治愈。术后平均进食时间(2.5±2.1)d,平均拔管时间(8.5±2.5)d,平均住院时间(13.7±3.9)d。所有中转开腹的患者均顺利出院,无围手术期死亡病例。结论腹腔内严重粘连、肝脏明显转位、术中出血止血困难、肝管狭窄是腹腔镜肝切除术治疗肝内胆管结石中转开腹的常见原因,应采用积极合理的方法避免中转开腹,但也要适时中转开腹,保证患者的安全。

Objective To investigate the causes and prevention of conversion to laparotomy in treatment of intrahepatic bile duct stones by laparoscopic hepatectomy.Methods Retrospective analysis was performed on clinical data of patients underwent laparoscopic hepatectomy for intrahepatic bile duct stones in Zhejiang Provincial People’s Hospital from Jan.2015 to Aug.2020 and.Results Among 165 patients,15 were transferred to laparotomy,the conversion rate was 9.1%;which including 6 males and 9 females,aged 34 to75 years,with a median age of 57 years;the Child-Pugh grades of liver function were all A/B.One patient was complicated with hypertension,and 1 patient was complicated with diabetes mellitus.Nine patients had abdominal surgery history.The average operation time was(245.7±55.3)min,and the average intraoperative blood loss was(383.3±321.5)mL.The causes for conversion to laparotomy:9 cases with severe intraperitoneal adhesions,2 cases with obvious hepatic translocation,2 cases with difficulty in hemostasis during operation,and 2 cases with right hepatic duct stenosis.Postoperative complications:celiac infection in 2 cases,pleural effusion in 4 cases,celiac infection with biliary tract infection in 1 case,and pleural effusion with biliary tract infection in 1 case.All patients were cured by conservative treatment.The average postoperative feeding time was(2.5±2.1)d,the average postoperative extubation time was(8.5±2.5)d,and the average postoperative hospitalization time was(13.7±3.9)d.All 15 patients were discharged from hospital without perioperative death.Conclusion Severe intra-abdominal adhesions,significant liver translocation,intraoperative hemorrhage and hemostasis difficulty,and hepatic duct stricture where stones located are common causes for the conversion to laparotomy in treatment of intrahepatic bile duct stones by laparoscopic hepatectomy.Positive and reasonable methods should be adopted to avoid conversion to laparotomy,but timely conversion to laparotomy should also be adopted to ensure the safety of patients.