经脐单切口腹腔镜肝管空肠Roux-en-Y吻合术治疗儿童胆总管囊肿的探讨.doc

经脐单切口腹腔镜肝管空肠肝管空肠吻合术 single-incision laparoscopic hepaticojejunostomy(SILH) for CDC in children. Methods We reviewed 19 children who underwent SILH between April and June 2011. Early postoperative and follow-up results were compared with our historical conventional laparoscopic hepaticojejunostomy(CLH) controls. Results The median follow-up period was 3 months. Two procedures were converted to the conventional 4-port laparoscopic hepaticojejunostomies. SILH was successfully completed in 17 patients(median age:3.00years,F/M:12/5). Early in the series, one patient developed bile leak which stopped spontaneously after 10 days of drainage. The mean operative time of the SILH group did not differ from that of our CLH controls(3.06 hours vs 3.04 hours, p=0.909). The average postoperative hospital stay, time to full feed and duration of drainage in the SILH group were comparable to our historical controls of CLH(p=0.056, 0.472, 0.619 respectively). Conclusion SILH is safe and its short-term results are comparable to CLH. It potentially provides a viable surgical alternative for CDC. 【Key words】：single-incision, laparoscopy, choledochal cysts, hepaticojejunostomy, children. 单孔腹腔镜技术越来越多地运用于成人外科领域，并开始运用与小儿，如：胆囊切除术、幽门肌切开术术肝管空肠肝管空肠肝管空肠°腹腔镜头，两侧操作孔分别置入电钩和直钳。 在腹腔镜直视下将20号套管针穿刺胆囊底，完成胆道造影。 在右肋缘下将2-0带针线穿入腹腔，穿过胆囊底浆膜后再穿出腹壁，悬吊胆囊及肝脏，暴露肝门部[图2]。第二根2-0缝线自剑突下穿入前腹壁及肝总管前壁，然后自右肋缘下右锁骨中线处穿出[图2,3a]。这种V形的悬吊技术可以使肝脏向上翻转，充分暴露肝门部。使用单极电刀自囊肿前壁开始向远端逐渐分离，直到囊肿后壁 [图3]。然后，在前壁横断囊肿，清尽囊肿内容物以扩大手术操作空间。此时横断囊肿后壁，分离后壁时尽量贴近囊肿后壁，以防损伤肝动脉及门静脉。 第三根2-0缝线将穿过并悬吊囊肿前壁中间部位，助手于腹壁外提拉牵引线，使胆总管远端暴露[图3a,3b]，这将有助于胰段胆总管的分离。为防止胰腺损伤，远端分离至胰胆管交界处为止[图3c]。常规进行肝内胆道探查，特别是合并肝总管狭窄或结石的患儿，我们将通过腹腔镜深入探查，了解狭窄位置并行肝管扩张成形术，彻底冲洗清除胆道蛋白栓和结石。 使用3mm电钩自浆膜下层自胆囊床分离胆囊。保留穿过胆囊底浆膜层的缝线牵引肝脏，以便于进行分离和吻合。 我们个体化设计每个患儿Roux胆支的长度，通常取患儿脐部至肝门部长度作为标准[6]。经脐拖出空肠，行空肠-空肠吻合后放回腹腔，重建气腹，自横结肠后隧道将Roux胆支提至肝门部[图3d]。使用5/0或6/0的PDS缝线在腹腔镜下行肝管空肠端-侧吻合[图3e]。根据吻合口直径，将一根双针线断为两根10-15cm长单针线，尾端相互打结，自肝总管6点处开始，分别向9点及3点方向进行连续缝合[图4a,4b]；后壁吻合完成后，同时自9点及3点方向收紧缝线，这样可以使肝总管及空肠吻合口完全对合[图4c]