【摘要】 目的腹腔镜手术出现胆管损伤后通常需要中转开放手术修复或二期手术,给患者增加极大的痛苦。能否采用腹腔镜手术的方法修复胆管损伤是一个值得探讨的问题。本研究的目的是探讨腹腔镜修复术治疗术中和术后早期发现的医源性胆管损伤的方法和可行性。方法总结分析2002年11月至2012年12月采用腹腔镜修复重建术治疗的11例术中或术后早期发现的医源性胆管损伤的资料。11例发生在腹腔镜胆囊切除术中(11/1485,0.74%)。男7例,女4例,平均年龄57.4岁(26~70岁)。其中6例为胆管轻度损伤,5例为高位胆管横断的重度胆管损伤。按刘允怡分类法,11例胆管损伤的损伤类型分别是:I型2例,ⅡA型2例,ⅢA型2例,ⅣA型3例,ⅣB型2例。9例胆管损伤在术中发现,另2例在术后2 d发现。针对不同的损伤类型采用不同的修复方法。2例肝总管部分轻度损伤(ⅡA型)的患者采用镜下缝合修补、T管引流来修复;1例右肝管孔状损伤的患者采用镜下单纯缝合修复;1例胆总管误扎的患者在镜下松解结扎线、胆总管探查、T管引流;1例胆囊床迷走小胆管横断的患者镜下缝扎封闭;1例胆囊颈残余胆漏的患者采用镜下切除残余胆囊、缝扎胆囊管的方法修复;另外5例高位胆管横断伤(肝总管或者左、右肝管横断伤)的患者采用镜下损伤的胆管对端吻合、硅胶支架管内引流的方法修复。结果 11例胆管损伤(BDI)患者均完全腹腔镜下一期修复术,无中转开腹手术。术后患者恢复顺利,无腹腔感染、无伤口感染等并发症发生。胆管修复术后平均住院时间是8.9 d(5~15 d)。患者均获得随访,随访时间8个月~10年不等。11例患者均无胆管狭窄。有1例患者发生过一次胆管炎,CT发现胆总管轻度扩张,行经内镜逆行性胰胆管造影术检查未发现胆总管结石,无胆管狭窄、肿瘤,考虑胆管轻度扩张为十二指肠乳头炎性狭窄引起,行经内镜下乳头括约肌切开术后治愈。其余10例患者无胆管炎、胆管狭窄等长期并发症。结论轻度胆管损伤可以采用镜下单纯缝合修补或T管引流治疗,胆管横断损伤可以采用腹腔镜下胆管对端吻合术、支架引流管内引流管术的治疗。腹腔镜下胆管修复术用于治疗医源性胆管损伤是有效可行的。然而,手术的难度极大,技术要求高,必须由具有丰富的胆道外科手术和娴熟的腹腔镜技术的专家进行手术。更多还原

【Abstract】 Objective Conversion to open surgery or two-stage operations were often needed when bile duct injuries(BDI)occurred, which would cause more pain to patients. It is worth to explore whether laparoscopic repair are suitable for BDI. The aim of the study is to explore the methods and feasibility of laparoscopic bileduct repair and reconstruction for BDI found during operation and in early postoperative period. Methods From Feburary 2002 to December 2012, 11 patients with BDI were treated with laparoscopic repairs during operation or in early postoperative period. The clinical data were collected and analyzed. 11 cases of BDI occurred in laparoscopic cholecystectomies (11/1485, 0.74%). 7 patients were male, and 4 patients were female. The mean age was 57.4 years(range 26-70 years). 6 BDI were mild injuries, and other 5 BDI were severe injuries(high-level bile duct transection).Wan-Yee Lau classification was used for these 11 BDI. 2 cases fell into type I,2 intoⅡA,2 into ⅢA,3 into ⅣA,2 into ⅣB. 9 BDI were found during operation, and the other 2 BDI were found on the second postopevative day. Different methods were used to repair BDI according to the type and severity of BDI.Laparoscopic suture and T-tube drainage were carried out in 2 mild partial common hepatic duct injuries(type Ⅱ A). Laparoscopic simple suture was performed in one patient with a hole-like injury in the right hepatic duct(type ⅣA). Laparoscopic common bile duct exploration, T-tube drainage, unfastening the thread were performed in one patient whose common bile duct was ligated incorrectly(type ⅢA). Laparoscopic closure by simple suturing was performed in one patient whose aberrant small bile duct at the gallbladder bed of live was injured(type I). The retained neck of gallbladder was resected and the cystic duct was sutured laparoscopically in one patient with retained neck of gallbladder and bile leak. Laparoscopic end-to-end bile duct anastomosis with silicone tube internal drainage were performed in 5 patients with high-level bile duct transection. Results Primary repaire of all 11 BDI were performed laparoscopically without conversion.They recovered very well without any complication. There was no death. The mean hospital stay was 8.9 days( range 5-15 days).11 patients received a follow-up from 8 months to 10 years.There was no bile duct stricture in the period of follow-up. One patient had cholangitis.Enhanced computed tomography scan showed mild dilated common bile duct. No bile duct stricture or tumor were found in ERCP. It was consider that the mild dilated common bile duct was caused by inflammatory stricture of Vater’s papilla.The patient was cured after a procedure of EST. There were no long-term complications such as cholangitis, bile duct stricture in the other 10 patients.Conclusions Mild BDI could be fixed up by laparoscopic simple suture or T tube drainage.Bile duct transection could be reconstructed by bile dut end-to-end anastomosis with silicone tube as stent for internal drainage. Laparoscopic repaire was feasible and effective for BDI. However, it is very difficult and technically demanding. Laparoscopic repair of BDI should be performed by biliary surgery specialist with excellent laparocopic skills.更多还原