腹腔镜胆囊切除术胆管损伤的防治

目的避免腹腔镜胆囊切除术胆管损伤的发生。方法回顾分析本院自1999年1月～2005年11月腹腔镜胆囊切除术512例。结果胆管损伤4例。结论严格的术前准备和规范的手术程序可以极大地减少腹腔镜胆囊切除术胆管损伤的发生。     

腹腔镜胆囊切除术中胆管损伤的分析

随着腹腔镜胆囊切除术 (ＬＣ)的广泛开展 ,其手术并发症也日益受到关注。尤其是ＬＣ术中所引起的胆管损伤 ,作为ＬＣ术中严重并发症的一种 ,各医疗单位也在不断地探讨有效的预防和处理的措施 ,但结果并未像ＬＣ初期所预料的那样 ,胆道损伤的发生率并未完全随着ＬＣ开展数量的增加而消失 ,而是稳定在一定水平上〔1〕。因此 ,我们仍有必要在ＬＣ开展初期总结的胆道损伤处置经验的基础上 ,进一步分析ＬＣ大量开展后胆道损伤的具体原因和处理措施。临床资料本文总结ＬＣ所致胆道损伤共 14例 ;其中来源于我院 34 0 0例 ( 1992～ 2 0 0 1年 )ＬＣ…     

腹腔镜胆囊切除术胆管损伤的护理

通过对７例腹腔镜胆囊切除术胆管损伤病人的护理，总结了腹腔镜胆囊切除术后加强对漏胆、腹腔感染、黄疸等胆管损伤的临床症状的观察，重点阐述了Ｔ形管的护理是胆管损伤重建手术后的护理重点。     

腹腔镜胆囊切除术中肝外胆管损伤的原因与预防

1991．9～1994.3月我院共做LC1750例，发生肝外胆管损伤4例，胆囊管残端瘘1例，迷走胆管损伤1例，外院转入LC术中胆管损伤2例，本文讨论LC术中肝外胆管损伤发生的原因及预防：(1)把胆总管误认为胆囊管将其钳闭切断，本组3例。     

腹腔镜胆囊切除术中胆管损伤的预防

目的 探讨腹腔镜胆囊切除术中胆管损伤的预防措施.方法 回顾性分析2002年12月～2007年12月484例腹腔镜胆囊切除术患者的临床资料,总结预防胆管损伤的经验.结果 本组患者无胆管损伤发生,中转开腹26例(5.37%),放置腹腔引流管20例.结论 熟悉胆管解剖,仔细地处理胆囊三角是避免LC术中胆管损伤的关键.     

腹腔镜胆囊切除术胆管损伤的防治

本院自１９９７年开展腹腔镜下胆囊切除术以来，胆管损伤时有发生。如何预防及正确处理腹腔镜胆囊切除术中胆管损伤，现将笔者的体会报告如下。临床资料１．一般资料：本组１０例，其中男性４例，女性６例；年龄３８～６９岁，平均５１岁。损伤部位：胆总管横断伤２例，胆总管裂开或缺损伤３例，钛夹钳夹胆囊管时胆总管误夹３例，右肝管裂伤２例。其中７例于术中发现，３例术后发现。２．结果：所有病例均进行及时正确处理，无一例死亡。其中１例病人术后仍间断出现腹痛、发热、黄疸等胆道感染症状，其余病人恢复良好。讨论胆石症是目前的常…     

腹腔镜胆囊切除术胆管损伤的防治

与开腹胆囊切除术 (ｏｐｅｎｃｈｏｌｅｃｙｓｔｅｃｔｏｍｙ ,ＯＣ)相比 ,腹腔镜胆囊切除术 (ｌａｐａｒｏｓｃｏｐｉｃｃｈｏｌｅｃｙｓｔｅｃｔｏｍｙ ,ＬＣ)胆管损伤的发生率相对较高。Ｄｅｚｉｅ[1] 分析美国 1117家医院的 7760 4病例 ,报道ＬＣ胆管损伤的发生率为 0 .5 9% ;Ｖｅｃｈｉｏ[2 ] 分析美国114 0 0 5病例 ,胆道损伤发生率为 0 .5 %。国内ＯＣ胆管损伤的发生率为 0 .15 %～ 0 .5 % [3 ] ,ＬＣ为 0 .3 2 %～ 0 .91% [4] 。但随着时间的推移 ,国内ＬＣ胆管损伤的发生率已有逐渐下降的趋势 ,1992年经 2 8家医院的调查为 0 .3 1%…     

电视腹腔镜胆囊切除术中胆管损伤的预防

目的　探讨腹腔镜胆囊切除术预防胆管损伤的经验。方法　总结应用腹腔镜行胆囊切除术 140例无胆管损伤的实践。结果　平均手术时间 85± 35分钟 ,术后 136例病人翌日可在扶助下下床活动和开始进食 ,术后住院 3～ 5天。 1例发生胆漏和 1例局限性腹腔感染均经保守治疗痊愈 ,2例因严重粘连解剖变异而中转开腹手术也痊愈 ,均无胆管损伤和大出血等严重并发症。结论从造成胆管损伤的常见原因着手 :1技术及人为因素 ;2对手术困难估计不足和适应症选择不当 ;3炎症粘连 ;4结石嵌顿 ;5解剖变异 ;6未能果断中转开腹手术 ;认真做好预防胆管损伤的工作。     

腹腔镜胆囊切除术致胆管损伤5例分析

自腹腔镜胆囊切除术(LC)引进我国后,因其安全、经济、创伤小、恢复快,且适应证广被医患双方认可,广泛应用于临床。我院自2002年6月-2004年6月共开展LC216例,其中损伤胆管5例,现总结分析如下：     

腹腔镜胆囊切除术后胆道损伤的处理策略

目的 探讨腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）术后胆道损伤时合理的处理策略.方法 回顾性分析11年间我院处理的17例LC手术后胆道损伤的临床资料,其中胆囊床小胆管损伤4例,采用缝扎或内镜下胆道引流;主要胆管部分损伤8例,采用单纯修补、内镜下引流、放置支架或胆管空肠Roux-en-Y吻合;胆总管或肝总管完全横断4例,予对端吻合或胆肠吻合;左右肝管横断1例,二期整形后行胆肠吻合.胆道再狭窄患者予内镜下扩张并置入支架,效果不佳者行胆肠吻合.结果 所有患者均无重大并发症发生,疗效满意.结论 LC手术胆道损伤重在预防,一旦损伤,需由有经验的胆道专科医生依据损伤情况选择干预方式,方能达到最好疗效.     

腹腔镜胆囊切除术中医源性胆管损伤的预防

腹腔镜胆囊切除术（LC）目前已定位为良性胆囊疾病的金标准手术。医源性胆管损伤（iatrogenic bile duct injury,IBDI）是其最严重的并发症之一。如发现不及时或处理不当都可能引起严重后果。因此,LC引发的胆管损伤应引起足够的重视。术者经验不足、局部粘连严重、出血、胆道解剖变异等是导致胆管损伤的主要原因。了解LC发生IBDI的风险因素,正确处理IBDI,对避免威胁病人生存质量的后果有非常重要的意义。     

Iatrogenic bile duct injury: the scourge of laparoscopic cholecystectomy

Background : Laparoscopic cholecystectomy (LC) has become the first‐line surgical treatment of calculous gall‐bladder disease and the benefits over open cholecystectomy are well known. In the early years of LC, the higher rate of bile duct injuries compared with open cholecystectomy was believed to be due to the ‘learning curve’ and would dissipate with increased experience. The purpose of the present paper was to review a tertiary referral unit’s experience of bile duct injuries induced by LC. Methods : A retrospective analysis was performed on all patients referred for management of an iatrogenic bile duct injury from 1981 to 2000. For injuries sustained at LC, details of time between LC and recognition of the injury, time from injury to definitive repair, type of injury, use of intraoperative cholangiography (IOC), definitive repair and postoperative outcome were recorded. The type of injury sustained at open cholecystectomy was similarly classified to allow the severity of injury to be compared. Results : There were 131 patients referred for management of an iatrogenic bile duct injury that occurred at open cholecystectomy (n = 62), liver resection (n = 5) and at LC (n = 64). Only 39% of bile duct injuries were recognized at the time of LC. Following conversion to open operation, half the subsequent procedures were considered inappropriate. When the injury was not recognized during LC, 70% of patients developed bile leak/peritonitis, almost half of whom were referred, whereas the rest underwent a variety of operative procedures by the referring surgeon. The remainder developed jaundice or abnormal liver function tests and cholangitis. An IOC was performed in 43% of cases, but failed to identify an injury in two‐thirds of patients. The bile duct injuries that occurred at LC were of greater severity than with open cholecystectomy. Following definitive repair, there was one death (1.6%). Ninety‐two per cent of patients had an uncomplicated recovery and there was one late stricture requiring surgical revision. Conclusions : The early prediction that the rate of injury during LC would decline substantially with increased experience has not been fulfilled. Bile duct injury that occurs at LC is of greater severity than with open cholecystectomy. Bile duct injury is recognized during LC in less than half the cases. Evidence is accruing that the use of cholangiography reduces the risk and severity of injury and, when correctly interpreted, increases the chance of recognition of bile duct injury during the procedure. Prevention is the key but, should an injury occur, referral to a specialist in biliary reconstructive surgery is indicated.     

Delayed presentation of bile duct injuries after laparoscopic cholecystectomy

Bile duct injury is a serious complication of laparoscopic cholecystectomy, with 50% of bile duct injuries showing a delayed presentation. We experienced four patients (one male and three female) with bile duct injuries after laparoscopic cholecystectomy performed and referred by a local practitioner. The patients' ages ranged from 34 to 63 years. Symptoms included abdominal pain, anorexia, jaundice, ascites, ileus, fever, and tarry stool. Ductal injuries were a result of electrocautery burn in two patients and biliary strictures were due to malapplication of endoclips in the remaining two. The observed bile duct injuries, confirmed by ultrasonography, computed tomography (CT) scanning, and cholangiographic studies, were successfully treated by choledochotomy with a silastic T-tube stent. To avoid bile duct injuries, laparoscopic cholecystectomy should be performed by a well trained and experienced hepatobiliary surgeon, who should ensure accurate identification of the anatomical structures of Calot's triangle, careful dissection and management of intraoperative bleeding, and a lower threshold for conversion to open surgery.     

LC引起的医源性右肝管、副肝管损伤的诊治

目的 分析腹腔镜胆囊切除术（LC）造成的医源性右肝管、副肝管损伤的特点及防治,探讨术中胆道造影（intraoperative cholangiography,IOC）对术后胆道通畅度评级的影响。方法 回顾性分析南京医科大学第一附属医院2014年5月至2021年11月诊治的20例医源性右肝管、副肝管损伤患者的损伤类型和损伤原因、治疗及随访结果。20例中11例未行术中胆道造影（非IOC组）,9例行术中行胆道造影（IOC组）,对比两组术后胆道通畅度评级。结果 右肝管损伤16例：8例行I期修补置管支撑引流,其中5例双T管置入;4例单纯修补;3例右肝管横断延期行胆肠吻合术;1例右肝管误缝扎,远期因梗阻行胆肠Roux-en-Y吻合术失败改行PTCD。4例副肝管损伤中1例修补并置管引流,1例术中误夹闭后胆瘘二期行胆肠吻合术,2例直接夹闭。IOC组术后胆道通畅度评级A级8例、C级1例,非IOC组GP A级3例、B级4例、C级3例、D级1例;IOC组评级优于非IOC组（P<0.05）。术后随访6~133个月,远期右肝管结石形成2例,胆管炎3例,右肝萎缩1例。结论 充分认识右肝管及副肝管的解剖特点,术中及时发现损伤,并根据损伤类型、IOC情况等制定相应策略是提高LC医源性胆管损伤疗效的关键。     

Comparison of major bile duct injuries following laparoscopic cholecystectomy and open cholecystectomy

BACKGROUND: The mechanism and extent of major bile duct injuries following laparoscopic cholecystectomy differ from those of open cholecystectomy. METHODS: To identify differences in the demographic profile, timing of injury detection, management strategies and outcome, we undertook a retrospective review and analysis of our experience with 55 major bile duct injuries following both laparoscopic and open cholecystectomies over a period of 9 years. RESULTS: Thirty-one major bile duct injuries resulted from laparoscopic cholecystectomy (56%) and 24 of them were sustained after open cholecystectomy (44%). The median time of presentation was 7 days after laparoscopic cholecystectomy and 14 days following open cholecystectomy (P < 0.001). Twenty-eight (51%) patients had injuries recognized intraoperatively in both groups, of whom 18 patients underwent an attempt at primary repair before referral. All patients required subsequent surgical intervention. There were no differences in the clinical presentations between the two groups. However, serum alkaline phosphatase, alanine aminotransferase and aspartate aminotransferase levels were significantly higher following open cholecystectomy (P < 0.05). There was no significant difference in the level of injury between the two groups. All patients underwent surgical repair in the form of a Roux-en-Y hepaticojejunostomy (including two revision hepaticojejunostomies in each group). Surgical outcome did not differ between the groups; however, better results were seen with Bismuth grades 1 and 2 strictures compared with Bismuth grades 3 and 4 strictures for both groups (P < 0.002). CONCLUSION: Major bile duct injuries following laparoscopic cholecystectomy present earlier and with lower levels of serum alkaline phosphatase, alanine aminotransferase and aspartate aminotransferase. There does not appear to be a significant difference between the Bismuth-Strasberg grading of the strictures and the type of surgery carried out.     

腹腔镜胆囊切除术胆管损伤的影像学特征及价值

胆管损伤（bile duct injury,BDI）是腹腔镜胆囊切除术最严重的并发症之一,若处理不及时或处理不当,甚至危及病人生命。BDI只有少部分是在术中及时发现的,多数是在术后出现症状及体征时才被发现,影像学技术有助于BDI的诊断及明确损伤部位和损伤类型,对制订完善的治疗方案有重要意义。B超、CT检查,因其无创伤性,为疑及BDI者最常用的诊断方法,其余主要经过胆道造影,显示胆道的损伤情况,包括术中胆道造影,或术后磁共振胰胆管造影、经皮经肝胆道造影、内镜下逆行胰胆管造影等。     

腹腔镜胆囊切除术胆管损伤及术后胆漏的临床分析

目的 分析腹腔镜胆囊切除术后胆漏及胆管损伤的原因、治疗方法及预后。方法 总结1999年1月～2005年7月7例腹腔镜术后胆漏及胆管损伤的患者，进行回顾性分析。结果 7例患者中2例迷走胆管漏，1例经腹腔引流后治愈，1例经B超引导穿刺引流后治愈；胆囊管残端漏1例，再次手术缝扎，胆总管探查取石放置T型管引流后治愈，肝总管损伤漏2例，1例用3-0可吸收线间断缝合，放置腹腔引流治愈，1例剖腹手术修补漏口，放置T型管支撑6个月；胆总管横断2例剖腹行胆总管端端吻合放置T管支撑6-7个月。术后随访1～3年，均恢复良好。结论 腹腔镜胆囊切除术后的胆漏及胆管损伤，应及时发现，正确处理。     

腹腔镜胆囊切除术胆管损伤危险因素分析

目的 分析腹腔镜胆囊切除术（LC）胆管损伤的危险因素。方法 回顾性分析湖南省浏阳市人民医院1999年10月至2010年12月所行4531例LC病人的临床资料,对出现胆管损伤病人各影响因素进行χ2检验,并分析胆管损伤的独立危险因素。结果 单因素分析显示：病人性别、炎症分期、B超示胆囊壁厚度、胆囊三角解剖和术者经验与胆总管损伤有关联（P＜0.05）。多因素非条件Logistic回归分析结果显示：胆囊三角解剖和术者经验是胆管损伤的独立危险因素（P＜0.05）。结论 胆囊三角解剖和术者经验是胆管损伤的独立危险因素。     

Right hepatic lobectomy for bile duct injury associated with major vascular occlusion after laparoscopic cholecystectomy

A 57-year-old woman underwent laparoscopic cholecystectomy (LC) for cholelithiasis. Continuous bile leak was observed beginning on the first postoperative day. Postoperative endoscopic retrograde cholangiography revealed bile leak through the common hepatic duct, and severe stenosis of the hepatic confluence. A total of three percutaneous transhepatic biliary drainage (PTBD) catheters were inserted to treat obstructive jaundice and cholangitis. The patient was referred to our hospital for surgery 118 days after LC. Cholangiography through the PTBD catheters demonstrated a hilar biliary obstruction. Celiac arteriography revealed obstruction of the right hepatic artery, and transarterial portography showed occlusion of the right anterior portal branch. On the basis of the cholangiographic and angiographic findings, we performed a right hepatic lobectomy with hepaticojejunostomy to resolve the bile duct obstruction and address the problem of major vascular occlusion. The patient's postoperative recovery was uneventful and she remains well 25 months after hepatectomy. We discuss a treatment strategy for bile duct injury suspected after LC, involving early investigation of the biliary tree and prompt intervention. Received for publication on May 17, 1999; accepted on July 12, 1999