摘要
背景与目的:腹腔镜胆囊切除术(LC)术中胆道损伤一旦发生,可能造成患者身心双重痛苦,丧失其微创治疗的真正意义.然而,在临床实践中却是胆道外科医师无法完全避免的不良事件.随着微创外科技术的不断发展,腹腔镜手术修复LC术中胆道损伤的案例逐渐被报道,但其安全性和有效性受到部分学者质疑,因而成为具有争议的话题.笔者就近年来开展的腹腔镜手术修复LC相关胆道损伤患者资料进行总结,探讨其可行性及安全性.方法:回顾性分析宁夏回族自治区人民医院肝胆外科于2019年3月-2023年3月11例行腹腔镜手术修复的LC相关胆道损伤患者临床与随访资料.LC术中胆道损伤以可疑胆汁漏及术中胆道造影为判断依据,LC术后胆道损伤根据患者临床表现及腹部计算机断层增强扫描、磁共振胆胰管成像及腹腔镜探查评估与确定.结果:11例患者中,男性4例、女性7例.患者胆道损伤分型采用Strasberg-Bismuth分型,其中C型3例、D型1例、E1型1例、E2型3例、E3型2例、E4型1例.所有患者均顺利完成胆道损伤修复手术,其中7例行LC术中即时胆道损伤修复手术(6例应用完全腹腔镜下胆管对端吻合术或修补术、1例应用腹腔镜辅助小切口肝肠吻合术),4例行LC术后早期胆道损伤修复手术(1例应用完全腹腔镜胆肠吻合术、3例采用腹腔镜辅助小切口肝肠吻合术).11例患者平均修复手术时间(173.63±44.33)min,中位术中出血量100(90-140)mL.所有患者围术期无死亡,未见胆管吻合口或肝肠吻合口胆汁漏、胆道出血等并发症发生,平均住院时间为(14.27±2.93)d.所有患者随访时间平均为(38.09±17.23)个月,除外1例Strasberg-Bismuth C型胆道损伤于腹腔镜右肝管修补术后3个月合并右肝管狭窄再次行腹腔镜下右肝管空肠吻合术取得痊愈,其余患者随访期间未见胆道狭窄、反流性胆管炎等并发症出现.结论:在具有相当腹腔镜技术的胆道外科中心应用腹腔镜技术修复LC相关胆道损伤是相对安全可行的,但应当针对胆管损伤Strasberg-Bismuth分型,准确把握手术适应证,以合理的修复手术策略宜早实施.
Abstract
Background and Aims:Once bile duct injury occurs during laparoscopic cholecystectomy(LC),it can cause both physical and psychological suffering for the patient,negating the actual benefits of minimally invasive surgery.However,it is an adverse event that biliary surgeons in clinical practice cannot altogether avoid.With the ongoing development of minimally invasive surgical techniques,cases of laparoscopic repair of bile duct injury during LC have increasingly been reported.However,some scholars have questioned the safety and efficacy of these procedures,making it a controversial topic.This study summarized the data of patients undergoing laparoscopic repair for LC-related bile duct injuries performed in recent years and explored their feasibility and safety.Methods:The clinical and follow-up data of 11 cases of LC-related bile duct injuries repaired through laparoscopic surgery at the Department of Hepatobiliary Surgery,Ningxia Hui Autonomous Region People's Hospital,from March 2019 to March 2023,were retrospectively analyzed.Bile duct injury during LC was diagnosed based on suspected bile leakage and intraoperative cholangiography.Bile duct injury after LC was assessed and confirmed through clinical manifestations,enhanced abdominal CT,MRCP,and laparoscopic exploration.Results:Among the 11 patients,4 were males and 7 were females.The Strasberg-Bismuth classification was used to categorize bile duct injury of patients,which included 3 cases of type C,1 case of type D,1 case of type E1,3 cases of type E2,2 cases of type E3,and 1 case of type E4.All patients completed the repair surgery of bile duct injury,of whom 7 cases underwent immediate intraoperative repair surgery(6 cases underwent total laparoscopic bile duct end-to-end anastomosis or repair,1 case underwent laparoscopic-assisted small incision hepaticojejunostomy),and 4 cases underwent early bile duct injury repair surgery following LC(1 underwent total laparoscopic biliary-enteric anastomosis and 3 underwent laparoscopic-assisted small incision hepaticojejunostomy).The average time for the repair surgery was(173.63±44.33)minutes,and the median intraoperative blood loss was 100(90-140)mL.There were no perioperative deaths,and no complications such as bile leakage or bile duct bleeding at the anastomosis sites were observed.The average length of hospital stay was(14.27±2.93)d.The average follow-up time for all patients was(38.09±17.23)months except for one patient with Strasberg-Bismuth type C bile duct injury who developed right hepatic duct stricture three months after laparoscopic proper hepatic duct repair and was successfully treated with laparoscopic right hepaticojejunostomy,no other complications,such as bile duct strictures or reflux cholangitis were observed during the follow-up period.Conclusion:In hepatobiliary centers with advanced laparoscopic techniques,performing laparoscopic surgery to repair LC-related bile duct injury is relatively safe and feasible.However,it is essential to accurately assess the indications for surgery based on the Strasberg-Bismuth classification of bile duct injury and to implement an appropriate repair strategy as early as possible.
基金项目
宁夏回族自治区重点研发计划基金资助项目(2019BEG03039)
维普
万方数据