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。
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 探讨胆管良性疾病再次手术的原因及其诊断与治疗。方法 回顾性分析1991年1月至2005年12月期间我院收治的胆管良性疾病再次手术91例患者的临床资料。结果 91例中接受2次手术者87例（95.60%），3次手术者4例（4.40%），无手术死亡。再次手术原因： 结石残留或复发42例（46.15%），胆管损伤36例（39.56%），残留胆囊5例（5.49%），胆肠吻合口狭窄2例（2.20%），返流性胆管炎2例（2.20%），胆总管下端炎性狭窄2例（2.20%），肠瘘2例（2.20%）； 再次手术方式： 胆肠Roux-en-Y吻合、T管支撑56例（61.54%），肝叶切除13例（14.29%），肝门整形、肝管空肠Roux-en-Y吻合10例（10.99%），残余胆囊切除5例（5.49%），胆总管切开取石、T管引流3例（3.29%），胆管修复、T管支撑2例（2.20%），胆管对端吻合、T管支撑2例（2.20%）。结论 降低结石残留以及预防胆管损伤是防止再次胆道手术的关键。进行胆道再次手术时应积极术前准备，制定合理治疗方案，以避免多次手术。
目的 探讨围手术期处理措施在胆管损伤（BDI）治疗中的作用。方法 分析我院1990年7月至2008年7月期间46例BDI患者的临床资料。结果 46例BDI患者术中发现32例，术后发现13例，1例外伤所致。2例BDI患者行二期胆管修复术后，死于漏胆引起的弥漫性腹膜炎及全身衰竭，1例十二指肠降部憩室手术胆胰管损伤死于并发症，2例胆肠吻合因反复胆管炎死于全身衰竭。结论 除手术措施外，围手术期处理措施对BDI预后有重要影响。应及时发现并处理BDI，术中胆管造影对诊断和治疗有指导意义，术后发现BDI并严重腹腔感染者，围手术期应选择恰当的非手术处理措施有效控制病情后决定手术时机。
Objective To investigate the anatomic factors on iatrogenic biliary injury for elevating surgical safety and decreasing incidence of iatrogenic biliary injury. Methods The clinical data of 39 patients with iatrogenic biliary injury and anatomic varied factors in operation records from January 2000 to August 2009 in The Second Affiliated Hospital of Kunming Medical College were analyzed retrospectively. Results Thirty-nine patients with iatrogenic biliary injury were divided into 5 types according to Bismuth typing, including type Ⅰ 6 cases, type Ⅱ 19 cases, type Ⅲ 8 cases, type Ⅳ 5 cases, and type Ⅴ 1 case. Anatomic varied factors included bile duct variation in 15 cases, cystic duct abnormal position in 10 cases, vascular variation in 13 cases, and porta hepatis rotation in 1 case. Biliary injuries were found during operation in 6 cases, 24—72 h after operation in 16 cases, and stenosis of biliary duct was found in 17 cases 3 months to 2 years after operation. Two cases were dead because of liver function failure or myocardial infarction, withdraw was 4, the other patients were cured. Conclusion Anatomic factors are important objective elements in iatrogenic biliary injury, paying attention to abnormal anatomic factors can effectively prevent iatrogenic biliary injury.
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.
目的探讨经皮经肝胆管穿刺引流（PTCD）、经皮腹腔穿刺引流及Roux-en-Y胆管空肠吻合术序贯治疗高位胆管损伤合并胆漏的疗效。方法对我中心2004年5月至2009年5月期间收治的5例高位胆管损伤合并胆漏的患者，应用PTCD、经皮腹腔穿刺引流、Roux-en-Y胆管空肠吻合术序贯治疗过程及疗效进行回顾性分析。结果5例患者均获痊愈，随访3~24个月，未发生胆管再次狭窄、胆管炎等并发症。结论PTCD、经皮腹腔穿刺引流后，再进行Roux-en-Y胆管空肠吻合术是治疗高位胆管损伤合并胆漏的首选方法。
目的 探讨三管一壶腹在腹腔镜胆囊切除术中的应用价值。方法 回顾性分析2011年9月至2012年6月期间九寨沟县人民医院外一科行腹腔镜胆囊切除术（术中均遵循三管一壶腹的解剖关系）的362例患者的临床资料。结果 362例患者中，慢性结石性胆囊炎317例，胆囊息肉45例。术中有3例（0.83%）患者中转开腹，2例（0.55%）患者发现副肝管，均未发生胆管损伤，无手术死亡。术后所有患者均随访半年，随访期间均无其他并发症发生，术后恢复均良好。结论 胆囊切除术中遵循三管一壶腹的解剖关系，可有效地预防胆管损伤等并发症的发生，其安全、可靠，值得推广应用。
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。
目的探讨腹腔镜胆囊切除（LC）术中胆管损伤的分型与处理。 方法回顾性分析我院2009年4月至2012年4月期间12例LC并发胆管损伤患者的首次手术过程及对胆管损伤的处理。 结果12例胆管损伤患者中手术中转开腹修补6例，术中未及时发现于术后3周内发现而再次手术6例。3例单纯胆管修补，6例行胆管修复T管支撑引流术，3例行胆管空肠Roux-en-Y吻合术。2例发生了不同程度的术后吻合口狭窄。全组无手术死亡病例。 结论熟悉胆囊三角（Calot三角）脉管变异及病理结构空间改变，熟练的手术操作，必要的中转开腹可减少胆管损伤的发生。损伤发生后及时合理的处理可获良好疗效，普外科医师在操作中应注意。