目的 总结腹腔镜胆囊切除术（LC）胆管损伤的特点和处理经验，以提高治愈率。方法 回顾性分析81例LC术中胆管损伤的临床资料。结果 49例肝总管刺破伤，及时于腹腔镜下缝合8例，中转开腹修补33例，术后发现再开腹修补8例； 12例胆总管横断伤，术中发现10例中转开腹行胆总管端端吻合术、T管支撑引流，术后发现2例先行腹腔引流，3个月后再行胆肠吻合； 8例胆总管部分夹闭者，行剖腹取钛夹、T管支撑胆管引流半年； 10例肝总管及胆总管缺损和2例肝总管缺损伴左、右肝管部分夹闭者，均先行引流，3个月后再行肝门胆管空肠吻合术。全组病例经上述治疗后均痊愈出院。结论 不同类型的胆管损伤应采用不同的方式在不同的时间进行相应处理可获良好疗效。
ObjectiveTo investigate and compare the advantages and disadvantages of laparoscopic cholecystolithotomy and laparoscopic cholecystectomy for patients with gallbladder stone. MethodsThe eligible patients with gallbladder stones hospitalized in our department between January 2007 and December 2011 were included, and all of them received either laparoscopic cholecystolithotomy (observation group) or laparoscopic cholecystectomy (control group) minimally-invasive surgery. The operation time, bleeding volume, enterokinesia recovery time, hospital stay, post-operative complication and follow-up results were compared between the two groups. ResultsA total of 148 patients were included, with 68 patients in the observation group and 80 patients in the control group. In this cohort, the success rate of surgery for the observation group and the control group was 100.0% (68/68) and 98.8% (79/80), respectively; and the success rate of complete stone removal was 100% for both two groups. B-ultrasound examination after 2 weeks of treatment showed that gallbladder wall was normal and gallbladder contraction rate was more than 30% for all patients with laparoscopic cholecystolithotomy. The operation time was (49.6±5.2) minutes for the observation group and (50.5±6.2) minutes for the control group, and bleeding volume was (9.5±1.4) mL for the observation group and (50.2±8.1) mL for the control group; the difference in bleeding volume was significant between the two groups (P<0.05). The difference in enterokinesia recovery time[(33.9±2.2) and (34.4±2.6) minutes] or hospital stay[(3.4±1.0) and (3.6±1.2) days] between the observation group and the control group was not significant (both P >0.05). The post-operative complications of bleeding, bile leakage and wound infection were not observed in both two groups, and all patients were followed up for 6 to 12 months with no stone recurrence; and only 2.7% of patients (1/37) had stone recurrence after 3-year follow-up. ConclusionBoth laparoscopic cholecystolithotomy and laparoscopic cholecystectomy procedures are safe and efficient. However, laparoscopic cholecystolithotomy not only reserves gallbladder but also has superiority of less bleeding volume.
Objective To explore the risk factors of postoperative portal vein system thrombus (PVST) after laparoscopic splenectomy in treatment of portal hypertension and hypersplenism. Methods Clinical data of 76 patients with portal hypertension and hypersplenism who underwent laparoscopic splenectomy in the Sichuan Provincial People’s Hospital from January 2012 to January 2017 were analyzed. Results There were 31 patients suffered from PVST (PVST group), and other 45 patients enrolled in non-PVST group.There were significant differences on age, diameter of splenic vein, diameter of portal vein, blood flow velocity of portal vein, level of D-dimer, and platelet count between the PVST group and the non-PVST group (P<0.05), but there were no significant difference on gender, Child-Pugh classification, etiology of cirrhosis, operation time, intraoperative blood loss, postoperative complications, and prothrombin time between the two groups (P>0.05). Multivariate logistic regression analysis showed that, patients with age >50 years (RR=1.31, P=0.02), splenic vein diameter >12 mm ( RR=1.29, P<0.01), portal vein diameter >13 mm (RR=1.55, P=0.01), blood flow velocity of portal vein <18 cm/s ( RR=1.47, P<0.01), increases level of D-dimer (RR=2.89, P=0.03), and elevated platelet count (RR=1.82 P=0.02) had higher risk of postoperative PVST than those patients with age ≤50 years, splenic vein diameter ≤12 mm, portal vein diameter ≤13 mm, blood flow velocity of portal vein ≥18 cm/s, normal level of D-dimer and platelet count. Conclusion For patients with portal hypertension and hypersplenism who underwent laparoscopic splenectomy, we should pay more attention to the risk factor, such as D-dimer and so on, to avoid the occurrence of postoperative PVST.
Objective To explore the measures for early diagnosis and treatment of iatrogenic injury in the distal part of common bile duct. Methods The clinical data of 20 patients with iatrogenic injury in the distal part of common bile duct treated in our hospital from 1990 to 2008 were analyzed retrospectively. Results The injuries of 15 cases were found during the operation: 11 cases were treated with 3-stoma (bile duct, pancreas, duodenum)+Oddi sphinctreoplasty (OSP), 1 case with OSP+choledochojejunostomy, 2 cases with the perforated common bile duct suture repair+T tube drainage, 1 case with T tube drainage; All of them were cured after surgery. The other 5 cases were not found during the primary operation, 2 cases in which were cured with several operations, the other 3 were dead from infectious shock. Conclusions Early diagnosis and treatment of iatrogenic injury in the distal part of common bite duct can obtain perfect effects. Different procedures should be performed according to different degrees of the injury. The perfect preoperative imaging examination and intraoperative choledochoscopy before bile duct exploration may reduce the occurrence of the injury.
目的探讨腹腔镜胆囊切除术(LC)术中用丝线结扎胆囊颈管和胆囊动脉的方法及临床效果。方法在13 159例LC 手术中,97%（12 745/13 159）不使用钛夹而采用普通丝线结扎胆囊颈管和胆囊动脉。结果占总病例73.0%的单纯性结石性胆囊炎、胆囊息肉和胆囊炎病例，平均手术时间21 min。急性胆囊炎、胆囊结石的病例，平均手术时间52 min。全部病例无一例因此方法处理胆囊颈管和胆囊动脉而发生术后胆漏、出血等并发症，恢复较快，术后3~5 d出院，患者体内无金属异物存在，无相应不良影响。结论丝线结扎胆囊颈管和胆囊动脉，操作简单，结扎可靠，缩短手术时间，减少术中损伤肝外胆管和邻近器官，降低术中风险，避免金属异物留置体内引起的不良影响，拓宽手术指征，更适用胆囊急性炎症期、胆囊颈管增粗的病例，其治愈率较高，并发症少。