微创外科技术在腹腔镜胆囊切除术后胆道再次手术中的应用

Application of Mini-invasive Surgical Technique in Biliary Reoperation after Laparoscopic Cholecystectomy

目的探讨腹腔镜胆囊切除(laparoscopic cholecystectomy,LC)术后胆道再次手术微创技术处理的方法和效果。方法回顾性分析我院肝胆外科2015年1月至2020年12月收治的322例LC术后再次胆道手术患者的临床资料。其中,胆总管残余结石187例(58.1%),胆管损伤35例(10.9%),胆管扩张或狭窄32例(9.9%),残余胆囊或胆囊管残留过长27例(8.4%),Oddi括约肌功能障碍32例(9.9%),胆总管异物4例(1.2%),意外胆囊癌5例(1.6%)。再手术距首次手术时间:LC术后1年内183例,1~5年者103例,5~10年者36例。结果再次胆道手术经ERCP采用不同附加手术206例(64.0%):胆管冲洗+ENBD 30例(9.3%),行球囊扩张取石/取异物118例(36.6%),EST 27例(8.4%),鼻胆管+B超引导下腹腔引流31例(9.6%);行腹腔镜手术93例(28.9%):LCBDE 39例(12.1%),残留胆囊、胆囊管切除术25例(7.8%),胆囊癌根治术3例(0.9%),胆肠吻合术26例(8.1%);开腹手术(含ERCP及腹腔镜中转开腹手术者)23例(7.1%):残留胆囊、胆囊管切除术2例(0.6%),胆囊癌根治术2例(0.6%),胆肠吻合术19例(5.9%)。行ERCP患者术后发生十二指肠乳头出血2例,术后一过性胰腺炎9例,十二指肠乳头插管失败5例转开腹手术;腹腔镜术中腹腔出血、胆管损伤各1例,均中转开腹手术;开腹手术发生腹腔感染2例。本组无围手术期死亡,围手术期并发症均经对症处理后痊愈出院。随访6个月~5年,6例再手术后3~5年死于其他疾病,13例再手术后1年内仍有肝胆管残余结石而行ERCP手术,其余患者症状消失。结论手术时机把握不当,术前诊断不确切,术中操作不规范导致术后并发症是LC术后再次胆道手术的主要原因;再手术时应在具备条件的区域性医疗中心进行,采用ERCP或腹腔镜等微创手术,疗效确切,可以减轻患者痛苦,加快康复。

Objective To explore the method and effect of mini-invasive technique in biliary reoperation after laparoscopic cholecystectomy(LC).Methods The clinical data of 322 patients performed biliary tract reoperation after LC admitted to our hospital from January 2015 to December 2020 were analyzed retrospectively,including 187 cases(58.1%)of residual choledocholithiasis,35 cases(10.9%)of bile duct injury,32 cases(9.9%)of bile duct dilatation or stenosis,27 cases(8.4%)of residual gallbladder or cystic duct too long,32 cases(9.9%)of Oddi sphincter dysfunction,4 cases(1.2%)of common bile duct foreign body,and 5 cases(1.6%)of accidental gallbladder cancer.The duration between reoperation and first operation was 1 year in 183 cases,1 to 5 years in 103 cases,and 5 to 10 years in 36 cases.Results Out of the 322 cases of biliary tract reoperation,206 cases(64.0%)underwent different additional operations via ERCP:30 cases(9.3%)of bile duct irrigation and ENBD,118 cases(36.6%)of balloon dilatation for the removal of stone or foreign body,27 cases(8.4%)of EST,and 31 cases(9.6%)of nasobiliary duct drainage and B-ultrasound guided abdominal drainage.93 cases(28.9%)underwent laparoscopic surgery,including 39 cases(12.1%)of LCBDE,25 cases(7.8%)of resection of residual gallbladder or bile duct,3 cases(0.9%)of radical cholecystectomy and 26 cases(8.1%)of choledochojejunostomy.Open surgery(including ERCP and laparoscopy conversed to open surgery)was performed in 23 cases(7.1%),including 2 cases(0.6%)of resection of residual gallbladder or bile duct,2 cases(0.6%)of radical cholecystectomy and 19 cases(5.9%)of choledochojejunostomy.In the ERCP cases,there was duodenal papilla bleeding occurred in 2 cases,postoperative transient pancreatitis in 9 cases,and open surgery transferred due to duodenal papilla intubation failure in 5 cases.One case of intraperitoneal hemorrhage and one case of bile duct injury occurred during laparoscopy,and both converted to open surgery.Abdominal infection occurred in 2 cases after laparotomy.All complications cured and discharged after symptomatic treatment without perioperative death.All cases were followed up for 6 months to 5 years.6 cases died of other diseases during 3 to 5 years after the reoperation,13 cases received ERCP surgery due to residual stones of the hepatobiliary duct within 1 year after the reoperation.The symptoms disappeared in other patients.Conclusions The postoperative complications due to inappropriate operation time,imprecise preoperative diagnosis and nonstandard intraoperative operating were the main reasons for biliary tract reoperation after LC.Mini-invasive reoperation,such as ERCP or laparoscopy,need to be carried out in some qualified regional medical centers,and to gain the effective curative effect,reduce the pain and accelerate the recovery.