双镜联合下胆囊管入路胆总管探查后一期缝合的体会.doc

双镜联合下胆囊管入路胆总管探查后一期缝合的体会邛崃市医疗中心医院普外科四川邛崠611530【摘要】目的探讨腹腔镜联合胆道镜经胆囊管行胆总管探查后一期缝合的手 术方法、临床效果及手术体会方法回顾分析2010年12月一2014年12月为 112例患者行两镜联合胆总管探查取石术的临床资料，根据术前彩超提示结石大 小和术中胆囊管及胆总管内径分为两组，其中胆囊管入路组31例(观察组)，胆 总管入路组81例(对照组)，对比分析两组手术时间、术中出血量、术后平均每 天胆漏量>20mL的例数、术后带管时间、住院时间、术后下床活动时间、术 后胆管狭窄率等指标结果两组均无中转开腹，两组手术时间［(81.5&plUSmn;37.1) min vs. (108.9 ± 33.5) min］、术中出血量［(29.8 ± 12.8) mL vs. (45.2 ± 9.80)011_］、住院时间［(7.6 ± 2.1)d vs. (13.2 ±4.1) d］、术后平均每天漏胆量>20mL的例数［1例］vs.［78例］、术后带管时间［(4.1 ± 1.3) d vs. (17.2 ± 11.1) d】差异有统计学意义(P<0.05);术 后下床活动时间［(23.6 ± 6.2) h vs. (25.3 ± 6.5) h］、术后胆管狭 窄率均为［0］差异无统计学意义(P> 0.05)o两组术后均无结石残留。

结论双 镜联合下胆囊管入路行胆总管探查一期缝合术与胆总管入路比较，前者术后并发 症少，痛苦轻，恢复快，只有生理功能干扰小，是目前较理想的微创治疗方法关键词】肝外胆管结石；胆囊管；腹腔镜检查；胆道镜检查；胆总管一期缝合Experience of primary common bile duct suture in choledochoscopic combined withlaparoscopic common bile duct exploration and lithotomy through cystic duct.REN Xiankun, WU Benhua, LIGuiquan，HUANG Jiabin, CHEN Changzhi(Department of General Surgery, Qionglai Medical Center Hospital，Qionglai,Sichuan 611530, China)Abstract： Objective To discuss the surgical procedure, clinical effect and experience of primary common bile duct suture in choledochoscopic combined with laparoscopic common bile duct exploration and lithotomy through cystic duct. Methods： Clinicalstatistics of patients who had the operation of choledochoscopic combined withlaparoscopic common bile duct exploration and lithotomy from December of 2010 to2014 were reviewed.The patients were divided into two groups according to the sizeof stones and inner diameter of cystic duct and common bile duct： 31 cases of cystic duct approach were in group A and 81 cases of common bile duct approach were in group B. We compare operation time, intraoperative blood loss, number of cases whoses average amount of bile leakage per day is geater than 20 mL，tube indwelling time, hospital stay, postoperative ambulance time，postoperative bile duct stenosis rate. Result： No patients were converted to laparotomy in two groups. There was significant difference (P<0.05) between two groups as for the operation time [(81. 5 ± 37. 1) min vs. (108. 9 ± 33. 5) min]，intraoperative blood loss[ (29.8 ± 12.8) mL vs. (45.2 ± 9.80) mL]，hospital stay [(7. 6 ± 2. 1) d vs. (13. 2 ± 4. 1) d]，the number of cases whoses average amount of bile leakage per day is greater than 20 mL[(23.6 ±6.2) h vs. (25.3 ± 6.5) h, the postoperative bile duct stenosis rate [1 case]vs[78 cases] and postoperative tube indwelling time[ (4.1±1.3) d vs. (17.2 ± 11.1) d]； while no significant difference (P>0.05) was found as for postoperative ambulance time[ (23. 6 ± 6. 2) h vs. (25. 3 ± 6. 5) h], postoperative bile duct stenosis rate[0 case for both].Neither of the groups had postoperative residual stone cases. Conclusion Comparing with common bileduct approach in primary common bile duct suture in laparoscopic common bile ductexploration and lithotomy，cystic duct approach has less postoperative complications, less pain and shorter recovering time and caused less disturbance to phisiologicalfunction. It is a kind of relatively ideal mini-invasive therapy.【Keywords】 Stones in Extrahepatic Bile Ducts； Cystic duct； Laparoscopy； Choledochoscopy； Primary common bile duct suture微创外科是二十一世纪外科发展的总方向，腹腔镜联合胆道镜治疗胆囊 结石和肝外胆管结石是目前常见的微创治疗方法之一。

随着胆道镜的广泛应用, 胆总管术后残石率己接近零，而术后留置T管造成的痛苦及恢复吋间逐渐成为需 解决的重点问题［1】胆总管探查一期缝合逐步在临床上得到应用，我院2010年 12月一2014年12月为112例肝外胆管结石患者于双镜联合下采用不同的手术入 路进行手术治疗，效果较好现报告如下1资料与方法1.1临床资料2010年12月一2014年12月为112例患者行两镜联合胆总管探查取石 术一期缝合，严格掌握开展胆总管一期缝合术的指征，既往文献提示以下为开展 的指征：(1)确认胆道不存在残余结石；(2)胆总管下端必须通畅；(3)无胆管狭 窄；⑷不存在急性化脓性胆管炎；(5)不合并胰腺炎［2］1) 胆囊管入路组：31例患者中男18例，女13例；平均 (53.4&plUSmn;5.9)岁胆囊结石合并胆总管结石21例，胆囊结石合并肝总管结石1例，急性胆囊炎合并胆总管结石6例，急性胆囊炎合并肝总管结石1例， 胆囊管结石2例胆囊管直径0.2〜0.4 cm 3例，胆囊管直径>0.4 cm的28例， 胆总管直径0.8〜1.0 cm 9例，>1.0cm22例胆总管单发结石24例，多发结石 7例;18例患者胆总管内结石直径0.3〜0.6 cm，13例为0.6-1.0cm;术前总胆红 素升高及肝功能异常25例、合并高血压5例、合并糖尿病7例、合并慢阻肺病 3例。

入组标准：术前腹部彩超、MRCP检查提示及术中胆囊管直径比较：判断 肝外胆管结石能够经胆囊管和胆囊管微切开取出者2) 胆总管入路组：81例患者中男54例，女27例；平均 (51.5&plUSmn;6.3)岁胆囊结石合并胆总管结石56例，胆囊结石合并肝总管结石13例，急性胆囊炎合并胆总管结石11例，急性胆囊炎合并肝总管结石1 例胆囊管直径0.2〜0.4 cm 52例，胆囊管直径>0.4 cm的29例，胆总管直径 0.8〜1.0 cm 29例，>1.0cm 52例胆总管单发结石18例，多发结石63例；11例患者胆总管内结石直径0.3〜0.6 cm，31例>0.6~1.0cm, 39例>1.0 cm，直径最大2.2 cm;术前总胆红素升高及肝功能异常73例、合并高血压9例、合并 糖尿病11例、合并慢阻肺病8例两组患者术前ASA病情分级均为I〜II级，临床资料差异无统计学意义1.2术前处理并发急性炎症的(胆囊炎和或胆管炎)的输注三代头孢类抗生素及解痉 药物；合并出血倾向的患者，静脉滴注维生素kl20mg/d;肝功能异常的患者， 行保护肝功能治疗；同吋控制糖尿病、高血压、慢阻肺、肺部感染等合并症。

1.3手术方法两组均全身麻醉，常规“四孔”法施术，气腹压力维持在10〜14 mmHg (1 mmHg = 0.133 kPa)之间，患者仰卧头高足低位首先解剖Calot三角，游 离胆囊管、胆囊动脉，可吸收生物夹夹闭胆囊动脉后用电钩切断，“掏空”胆囊 三角区组织，近胆囊壶腹部上一枚钛夹，夹闭胆囊管，暂不剪断胆囊管，不管是 哪一组，一助均可以牵拉胆囊予以暴露胆总管术中两组常规安置腹腔引流管于 温氏孔处1) 胆囊管入路组：完成胆囊三角区操作后，沿胆囊管汇入部长轴纵 行切开胆囊管，必要时采用微切开至胆总管汇合部，扩大胆囊管开口，以便插入 胆道镜及取石钳取石胆总管壁的切口最好不能超过3 mm,如胆囊管直径太细， 可适当扩张后插入胆道镜用取石网篮取尽胆总管内结石术中需持续注入生理 盐水冲洗(肝总管结石，应先将结石挤压至胆总管，再行取出)取石完毕于。