腹腔镜胆囊切除术致胆管损伤1例分析1例分析.docVIP

????????????????腹腔镜胆囊切除术致胆管损伤11例分析???????????????? 作者：汪学伦，张庆仪，祝建勇【摘要】? 目的? 探索腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）致胆管损伤的防治策略。方法? 回顾性分析1991年6月～2005年11月我科施行的138595例腹腔镜胆囊切除术中发生11例胆管损伤的原因及处理措施。结果? 本组9例小破口损伤（破损范围在3mm以下），行可吸收线一期修补及T管引流；2例破损严重者行胆肠Roux-en-Y吻合术。随访6个月～12年，无胆管狭窄、继发性结石等并发症发生。结论? 解剖变异、病变程度、术者的责任心和技术因素是LC致胆管损伤的主要原因。胆道损伤应及时发现，根据分型正确处理，以达到满意的预后。 　　【关键词】? 腹腔镜；胆囊切除术；胆管损伤 　　Analysis of 11 cases of bile duct injury in laparoscopic cholecystectomy 　　【Abstract】? Objective? To explore the preventive and therapeutic strategy of bile duct injury caused by laparoscopic cholecystectomy(LC）.Methods? We retrospectively analyzed 11 cases of bile duct injury in 138595 cases of laparoscopic cholecystectomy performed from June 1991 to November 2005.Results? According to Strasberg classification,9 cases(Type ）with diameter≤3mm were cured by sewing up the wound of bile duct and placing T type tube to drain bile,while the other two cases(Type V and ）were cured by cholangioplasty and cholangiojejunum Roux-en-Y anastomosis.Through 6 months to 12 years’ follow-up,no such complications as bile duct stricture or lithiasis were found.Conclusion? The primary reason is lack of understanding of the anatomy variety and pathological change,as well as responsibility and experience or skill of the operaters.The bile duct injury caused by LC should be found and tackled in time in order to achieve?? satisfactory prognosis. 　　【Key words】? laparoscope;cholecystectomy;bile duct injury 　　腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）已经成为临床治疗胆囊良性病变的首选术式，但出血、胆漏、胆管损伤等并发症仍然是影响LC疗效和安全性的重要因素。其中胆管损伤是最严重的并发症，文献报道其发生率为0.32%［1］。我科自1991年6月在国内率先开展LC，至2005年11月已施行138595例，发生肝外胆管损伤11例（0.008%），明显低于国内平均水平，现就其发生原因及处理措施进行回顾性分析，总结经验教训，探讨防治的策略。 　　1? 资料与方法 　　1.1? 一般资料? 本组11例患者，男10例，女1例，年龄27～68岁，平均41.6岁。术前诊断除1例为胆囊多发性息肉外，其余10例均为胆囊结石伴胆囊炎，其中急性胆囊炎6例，慢性胆囊炎2例，萎缩性胆囊炎2例。11例均有反复发作的右上腹部疼痛、发热等病史，病程6个月～15年。上腹部B超提示胆囊壁毛糙、增厚、边缘不清，胆囊腔内可见结石或息肉，后伴减弱回声。 　　1.2? 手术方法? 本组患者均在气管插管全麻下进行，采用的手术方法有四戳孔法和三戳孔法。四戳孔法于脐部做第一孔，造气腹后插入10mm套管，直视下在剑突下、右锁骨中线肋缘下及右腋前线肋