目的 探讨如何预防腹腔镜胆囊切除术(LC)中的胆管损伤。方法 回顾性分析2006年1月至2008年12月期间在我院行LC的657例患者的临床资料，总结预防胆管损伤的经验。结果 651例患者完成LC，中转开腹手术6例(0.91%)，其中1例(0.15%)因Calot三角致密粘连误伤胆总管。术后胆囊床毛细胆管渗漏2例，每日经腹腔引流管引出胆汁性液体20～50 ml，7～10 d 治愈出院。术后578例（包括中转开腹6例）患者获随访,随访率为87.98%，随访时间为2～24个月, 平均14个月。23例患者剑突下隐痛, 4个月内均自行消失，其余患者均未发现并发症。结论 严格掌握手术适应证、正确仔细地处理Calot三角和适时中转开腹是预防LC术中胆管损伤的关键。
Objective To summarize the classification, diagnosis, and treatment of iatrogenic bile duct injury. Method The clinical data of 27 cases of iatrogenic bile duct injuries who treated in Central Hospital of Huzhou City from 2008–2013 were retrospectively analyzed. Results The classification of 27 cases: 5 cases of type Ⅰ, 18 cases of type Ⅱ, 2 cases of type Ⅲ, 2 cases of type Ⅳ. Diagnosis: 11 cases were immediately discovered at the time of the initial operation, include 1 case of type Ⅰ, 8 cases of type Ⅱ, 1 case of type Ⅲ, 1 case of type Ⅳ; 10 cases were detected in early stage after the initial operation, include 2 cases of type Ⅰ, 7 cases of type Ⅱ, 1 case of type Ⅲ; 6 cases were detected in delayed stage after the initial operation, include 2 cases of type Ⅰ, 3 cases of type Ⅱ, 1 case of type Ⅳ. Treatment effect: 17 cases for excellent, 5 cases for good, 4 cases for bad, the well recover rate was 84.6% (22/26). One case died after operation. A total of 26 cases were followed up, 1 case was lost to follow up. During the follow-up period, bile leakage occurred in 3 cases, infection of incision occurred in 2 cases, cholangitis occurred in 3 cases, and bile duct stricture occurred in 2 cases. Conclusions The best time of repairing for the iatrogenic bile duct injuries is at the time of the initial operation or early stage. According to the type of injury and the time of the injury was diagnosed, timely and effective treatment by intervention and (or) surgery is the key.
ObjectiveTo investigate the clinical value of laparoscopic cholecystectomy following “A-B-D” approach applied in the operation of acute suppurative or gangrenous cholecystitis.MethodsWe sought out 45 patients diagnosed as acute suppurative or gangrenous cholecystitis and treated by laparoscopic cholecystectomy following the “A-B-D” approach in People’s Hospital of Leshan from Sep. 2019 to Dec. 2020 as the observation group (ABD observation group), and sought out 50 patients with the same diseases but treated by conventional laparoscopic cholecystectomy from Jun. 2018 to Aug. 2019 as the matched group (conventional matched group). We analyzed and compared the parameters related to safety and efficacy of the two groups retrospectively.ResultsA total of 95 patients were included, including 45 patients in the ABD observation group (26 cases of acute suppurative cholecystitis, 19 cases of acute gangrenous cholecystitis) and 50 patients in the conventional matched group (24 cases of acute suppurative cholecystitis, 26 cases of acute gangrenous cholecystitis). There were no significant differences in age, gender, body mass index, disease composition, gallbladder condition, and preoperative complications between the two groups (P>0.05). There was no bile duct injury case in the ABD observation group (0), while there were 4 cases (8.0%) in the conventional matched group, but the statistical results showed no statistical significance between the two groups (P=0.054). One case (2.2%) in the ABD observation group converted to laparotomy, which was significantly lower than the 10 cases (20.0%) in the conventional matched group, and the difference was statistically significant (P=0.017). In addition, there were no significant differences for other parameters including operative time, postoperative hospital stay, incidences of intraoperative bleeding and postoperative bleeding between the two groups (P>0.05).ConclusionsThe laparoscopic cholecystectomy following the “A-B-D” approach can help distinguish the anatomical structure of cystic duct and extrahepatic bile duct clearly, and it can help prevent biliary tract injury effectively and reduce the probability of conversion to laparotomy. It is worthy of clinical application and promotion, especially in the majority of county hospitals.
目的 探讨腹腔镜胆囊切除术中避免胆管损伤新方法的安全性。方法 回顾性分析2008年1月至2012年1月期间笔者所在医院采用Rouviere沟引导定位的方法进行腹腔镜胆囊切除术患者的临床资料，并在手术时间和术后并发症发生率方面与同期传统手术组病例相比较。结果 与传统手术组比较，Rouviere沟引导组患者的手术时间缩短，术后并发症发生率及中转开腹率降低，其差异均有统计学意义（P＜0.05）。结论 采用Rouviere沟引导定位法进行腹腔镜胆囊切除术能有效缩短手术时间，减少胆管损伤的发生概率，值得在临床推广应用。
ObjectiveTo explore technical essentials and safety of laparoscopic cholecystectomy (LC) guided by gallbladder ampulla localization on an imaginary clock for cholecystitis.MethodsA retrospective study of 8 707 continuous patients with mild cholecystitis who underwent LC from July 1998 to February 2018 at a single institution was conducted. Among them, 3 168 patients were treated by the traditional LC from July 1998 to February 2007 (a traditional LC group), 5 539 patients were treated by the LC with the guidance of the gallbladder ampulla localization on an imaginary clock from March 2007 to February 2018 (a gallbladder ampulla localization group). The conversion to open surgery, bile duct injury, return to the operating room due to postoperative massive abdominal bleeding, bile leakage without bile duct injury, operative time, intraoperative blood loss, and postoperative hospital stays were compared between the traditional LC group and the gallbladder ampulla localization group.ResultsThere were no significant differences in the gender, age, course of disease, and type of cholecystitis between these two groups (P>0.050). The rates of conversion to open surgery, bile duct injury, return to the operating room due to postoperative massive abdominal bleeding, bile leakage without bile duct injury and the operative time, intraoperative blood loss and postoperative hospital stays in the traditional LC group were 3.00% (95/3 168), 0.13% (4/3 168), 0.09% (3/3 168), 0.03% (1/3 168), (43.6±12.6) min, (18.7±3.3) mL, (3.6±2.7) d, respectively, which in the gallbladder ampulla localization group were 0 (0/5 539), 0 (0/5 539), 0 (0/5 539), 0 (0/5 539), (32.2±10.5) min, (12.4±3.5) mL, (3.5±2.8) d, respectively. The differences of conversion to open surgery, bile duct injury, return to the operating room due to postoperative massive abdominal bleeding rates, and the operative time and intraoperative blood loss were statistically significant between these two groups (P<0.050). The differences of the bile leakage without bile duct injury rate and postoperative hospital stays were not statistically significant between the two groups (P>0.050).ConclusionThis study shows that gallbladder ampulla localization on an imaginary clock is useful for ductal identification so as to reduce bile duct injury and improve safety of LC in case of no conversion to open surgery.
目的探讨胆囊切除术后再次手术的原因及其防治措施。方法对近6年我院收治的胆囊切除术后仍有症状，经B超、ERCP、MRCP、腹部X线平片及十二指肠低张造影等检查发现需再次手术的81例患者的临床资料进行回顾性分析，并结合文献，对其常见原因及其预防治疗措施进行了讨论。结果81例患者根据不同病因予以了相应的手术，如残株胆囊切除术、胆总管切开取石术、十二指肠憩室手术等。再次手术均取得良好效果，无手术死亡。结论对胆囊切除术后仍有症状者应作全面检查，部分患者可找出原因进行相应治疗，能取得良好效果； 而且绝大部分的再次手术，通过术前评估及术中各种技巧的应用是可以防范的。
【Abstract】ObjectiveTo evaluate the injury of common bile duct in immediate removal of the ligation in cholecystectomy. MethodsEighteen healthy Japanese rabbits were selected and divided into three groups randomly: A group treated with simple cholecystectomy, B group with cholecystectomy plus common bile duct crossligation and C group with cholecystectomy plus hepatic bile duct conjunction “Y”type ligation. The ligation was removed after 5 min in B and C groups. The levels of serum transaminase and bilirubin and pathological changes of bile duct and liver in each group were observed respectively. ResultsThere were no statistic difference in the levels of GPT, GOT, total bilirubin (TB), direct bilirubin (DB) and DB/TB on 12 hours before operation and the 1st and 7th day after operation between A and ligation groups (Pgt;0.05). But there were statistic difference in the those indexes and pathological changes of bile duct and liver between A and ligation groups on the 30th and 90th day after operation (Plt;0.05). ConclusionDuring cholecystectomy, immediate removal of common bile duct ligation doesn’t affect shortterm results, but the long-term results are bile duct stricture and obstruction.
ObjectiveTo explore the cause, clinical diagnosis and treatment, and prevention strategies of iatrogenic bile duct injury (IBDI). MethodsBy means of literature retrieval, the clinical diagnosis and treatment measures of patients with IBDI were summarized. ResultsThe related risk factors of IBDI include man-made factors, the local anatomy variation factors, and pathological factors. According to the damage diagnosis time and local pathological state, the repair operations such as bile duct suture repair, biliary tract end to end anastomosis, bile duct jejunum Roux-en-Y anastomosis, bile duct jejunum Roux-en-Y anastomosis, and jejunal artificial valve forming, or liver resection, and liver transplantation were performed. Moreover, it was also available that biliary stent or papillary balloon dilation through ERCP for the bile duct distal stricture. ConclusionsIt is important that prevention of IBDI. Operation should pay attention to upper abdominal operation prior to the implementation of the correct understanding of IBDI. In case of IBDI, the reasonable repair operation mode should be choose according to the damage types and time, and it can significantly improve the treatment effect and quality of life of patients.
31 cases of iatrogenic cholangic injury reported. 28 cases followed from 9 months to 6 years. iatrogenic cholangic injury is not an uncommon occurence main cases are inregular procedures, and carelessness in this group, only 9 cases were found intraoperatively. The main manifestations after injury were aggravating jaundice and/or bilious peritonitis. Symptoms, signs, B-type ultrsound and sometimes ERCP were used for diagnosis. Once the injury ascertained ends are the best treatment, an alternative Roux-Y Cholangiojejunostomy was also commonly used. In this group, 4 cases received the first methos and all with good results; 23 patients treated by the second methos, 17 were uneventful, 4 experienced more or less abdomenal pain, 2 suffered difinite repeated cholangitis and another 1 died.
目的总结胆囊切除术致医源性胆管损伤的原因、诊断、治疗及预防的经验。方法回顾性分析昆明市第一人民医院2006年5月至2011年5月期间经治的17例胆囊切除术致医源性胆管损伤患者的临床资料。结果损伤部位包括隆突2例，肝总管3例，胆囊管汇入胆总管部7例，胆总管4例，副肝管1例。1例一期术中端端吻合，2例一期吻合并留置T管支撑，1例行胆囊管结扎，2例内镜下留置鼻胆管引流，4例术后内镜下留置胆管支架，6例术后行胆肠Roux-en-Y吻合，1例行脱细胞基质材料修补。随访0.3～5年，平均2.3年，效果良好16例，1例反复发生胆管炎。结论医源性胆管损伤重在预防，精细解剖胆囊三角、严格遵循“确认-剪断-确认”三步骤是防止医源性胆管损伤的关键; 及时发现和正确的处理方法是降低其死亡率及改善预后的关键。