腹腔镜胆囊切除术胆管横断性损伤原因及对策.docVIP

腹腔镜胆囊切除术胆管横断性损伤原因及对策 　【摘要】 　　目的：探讨腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）致胆管损伤的特点及处理方法。方法：回顾总结3例LC术中胆管横断伤的临床资料，分析3例胆管横断性损伤的原因及对策。结果：胆管横断性损伤3例，术中发现1例，术后发现2例；胆管修补（端端吻合）+T管支撑引流1例，胆肠RouxenY吻合2例。结论：规范腹腔镜医师培训，提高腹腔镜操作技术，严把手术质量关，避免盲目自信，重视解剖变异、病理性异常，及时中转手术是预防胆道损伤的关键。 【关键词】 胆囊切除术,腹腔镜；胆道损伤;预防;治疗 　　Causes and management of bile duct injury caused during laparoscopic cholecystectomy 【Abstract】Ｏbjective:To explore the characteristics and management of bile duct injury caused during laparoscopic cholecystectomy.Methods:Clinical data of 3 cases of bile duct injury caused during laparoscopic cholecystectomy were analyzed retrospectively.Results:Three cases had transection injury of biliary duct.1 case was found during the operation and 2 cases were found after the operation.1 case received bile duct repair (endtoend anastomosis) and Ttube supporting and drainage;2 cases underwent choleenteroanastomosis (RouxenY).All the cases were cured.Conclusions:Familiar with the anatomy of porta hepatis,careful handling of the Calot′s triangle,proper conversion to laparotomy,and avoiding of blind confidence can mutually reduce the incidence rate of bile duct injury. 【Key words】 Cholecystectomy,laparoscopic;Bile duct injury;Prevention;Treatment 近年由于胆囊疾病发生率的增加和腹腔镜手术的普及，因胆囊切除手术所致的胆道损伤逐渐增多［１］。胆道损伤是腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)最为常见的严重并发症,处理往往较为困难且后果严重。笔者回顾分析了我院发生的3例胆管横断性损伤患者的临床资料，现报道如下。 　　1 资料与方法 例1男，41岁。右上腹反复疼痛不适10月余，绞痛发作2次，经抗炎、补液好转。B超检查示胆囊长10.1cm，宽4.3cm，囊壁毛糙，壁厚0.6cm，颈部及底部各见数枚强光团，最大1.1cm；胆总管内径0.5cm。腹腔镜下见胆囊肿胀、壁厚，Calot三角冰冻状粘连，沿胆囊壶腹向下分离胆囊管，置夹切断；向上分离切断三角内组织，发现有一管状断端流出胆汁，考虑胆管损伤中转开腹。术中见胆总管、肝总管离断，肝外胆管节段性缺损2.5cm，肝总管残留0.8cm，切除胆囊后纵形切开部分肝总管，行肝总管空肠RouxenY吻合术。解剖胆囊，见肝总管与胆囊壶腹紧密粘连无间隙，胆囊管极短约3mm，胆囊颈部有一枚直径1.2cm结石嵌顿。术后发现大量胆漏，第２天再次手术，置胆肠吻合口支架管引流，治愈出院。随访3年，早期频发胆管炎，经间断口服氟哌酸、小剂量强的松和消炎利胆片控制，目前仍偶有胆管炎发作。 例2女，38岁。右上腹疼痛5h。B超检查示胆囊长7.0cm，宽2.9cm。囊壁毛糙，厚约0.5cm，底部探及多枚强光团堆积，胆总管内径0.5cm。腹腔镜下见Calot三角脂肪组织堆积，分离胆囊管后，置夹切断；向上分离胆囊三角，发现一细小管状有胆汁溢出，考虑副肝管，置夹夹闭。术后第２天腰背部胀痛，无黄疸，B超检查示胆囊窝少量积液。术后第３天下腹痛伴肌卫腹膜炎表现，考虑副肝管漏，行剖腹探查术