腹腔镜联合胆道镜经胆囊管治疗胆囊结石合并胆总管结石的临床分析

梁 刚， 马富平， 何盟国

(1 陕西省核工业二一五医院 肝胆外科， 陕西 咸阳 712000； 2 咸阳市中心医院， 陕西 咸阳 712000)

腹腔镜联合胆道镜经胆囊管治疗胆囊结石合并胆总管结石的临床分析

梁 刚1， 马富平2， 何盟国1

(1 陕西省核工业二一五医院 肝胆外科， 陕西 咸阳 712000； 2 咸阳市中心医院， 陕西 咸阳 712000)

目的探讨应用腹腔镜联合胆道镜经胆囊管行胆道探查治疗胆囊结石合并胆总管结石的临床效果。方法对2014年1月-2015年12月陕西省核工业二一五医院收治的52例胆囊结石合并胆总管结石患者行腹腔镜联合胆道镜经胆囊管胆道探查取石术，观察其临床效果。结果52例患者中40例顺利完成手术，手术成功率为76.92%。7例改为腹腔镜下胆总管切开取石、T管引流术，5例中转开腹行胆总管切开取石、T管引流术，中转开腹率9.62%。43例患者一次取石成功，占82.69%；剩余9例患者行二次取石，其中行经胆囊管胆道探查取石术者8例，行腹腔镜下胆总管切开取石术者1例。所有患者术后留置网膜孔引流管，术后3～10 d拔除，1例行腹腔镜下胆总管切开取石患者术后出现胆漏，经保守治疗后康复。无胆道出血、胆道感染等发生，平均住院时间(8.24±2.52)d，所有患者均得到随访1年，B超及磁共振胰胆管造影检查肝内外未见结石残留，肝功能胆红素指标正常。结论腹腔镜联合胆道镜经胆囊管进行胆道探查取石术具有创伤小、患者恢复快、并发症少、安全等优点，临床应用需严格掌握其适应证。

胆囊结石病； 胆总管结石； 腹腔镜检查； 胆道镜； 治疗

随着微创技术在胆道外科中的应用，采用腹腔镜联合胆道镜进行胆囊切除、胆总管探查、T管引流术治疗胆囊结石合并胆总管结石，已经逐渐在临床中开展，并取得了较好的效果[1-2]。但是，胆道探查术后长时间留置T管具有诱发胆总管结石形成、胆汁丢失导致内环境失衡、护理不便等缺点。近年来，腹腔镜下胆道镜经胆囊管胆总管探查取石术(laparoscopic transcystic common bile duct exploration，LTCBDE)，逐步开展通过机体生理管道(胆囊管)行胆总管探查取石，不必切开胆总管，减少了胆管损伤风险，且术后无需留置T管[3]。本研究回顾性分析了LTCBDE治疗胆囊结石合并胆总管结石患者的临床资料，报告如下。

1 资料与方法

1.1 研究对象 收集2014年1月-2015年12月陕西省核工业二一五医院收治的行LTCBDE患者52例，其中男25例，女27例，年龄40～70岁，平均(65.32±8.24)岁。20例患者无上腹部症状，32例患者反复出现右上腹疼痛，所有患者均无发热、寒战症状。52例患者经B超或磁共振胰胆管造影(MRCP)检查诊断为胆囊结石合并胆总管结石，胆囊颈部无结石嵌顿，胆囊管直径约0.4～0.5 cm。胆总管直径最宽1.30 cm，最窄0.92 cm，平均(1.12±0.45)cm。胆总管结石最大1.10 cm，最小0.40 cm，平均(0.72±0.25)cm。胆总管单发结石32例，多发结石20例。不同程度血清TBil和DBil水平升高、转氨酶升高者16例。所有患者排除急性胆囊炎、急性胆管炎、急性胰腺炎。

1.2 手术方法 麻醉成功后，常规三孔法建立气腹，术中术野显露不佳时改为四孔法。合并胆囊结石者，先于腹腔镜下解剖出胆囊管和胆囊动脉，仔细分离胆囊管和胆总管汇合处，辨清胆囊管、肝总管、胆总管的解剖关系。胆囊动脉夹闭后电凝切断，在胆囊管和胆总管汇合处远端约1 cm用钛夹夹闭胆囊管，并于胆囊管和胆总管汇合处远端约0.6 cm斜形部分剪开胆囊颈部胆囊管。若胆囊管内径允许，直接插入胆道镜(Olympus CHF P20Q，直径5 mm)；若胆道镜进入困难，可采用球囊导管扩张胆囊管或沿胆囊管长轴剪开胆总管前壁0.2～0.5 cm，插入胆道镜进行胆总管探查，用取石网篮(Wilson WF-1810 GL520)取出结石。结石较大时，可碎石后取出。取净结石后，若完整的胆囊管近端距胆总管>0.3 cm，可用生物夹夹闭胆囊管近端；如胆囊管残留部分过短或沿着胆囊管剪开胆总管前壁的，可用4-0薇乔线缝合关闭胆囊管残端或胆总管切口。切除并取出胆囊，于Winslow孔处放置橡胶引流管。

2 结果

52例患者中40例顺利完成手术，手术成功率为76.92%。7例改为腹腔镜下胆总管切开取石、T管引流术，5例中转开腹行胆总管切开取石、T管引流术，中转开腹率9.62%。43例患者一次取石成功，占82.69%；余9例患者行二次取石，其中行经胆囊管胆道探查取石术者8例，行腹腔镜下胆总管切开取石术者1例。平均手术时间(54.7±8.4)min，平均出血量(30±12)ml，术后肠功能平均恢复时间(1.2±0.4)d。所有患者术后留置网膜孔引流管，术后3～10 d拔除。1例行腹腔镜下胆总管切开取石患者术后出现胆漏，经保守治疗后康复；无胆道出血、胆道感染等发生，平均住院时间(8.24±2.52)d，所有患者均随访1年，B超及MRCP检查肝内外未见结石残留，肝功能胆红素指标正常。

3 讨论

LTCBDE利用自然管道进行胆总管结石治疗，术中可避免损伤胆总管，相比腹腔镜下胆总管切开取石、T管引流术，具有更加微创、安全的优势[4]。同时，也可避免术后长期留置T管给患者带来的痛苦及相关并发症[5]。近年来，LTCBDE逐渐成为临床上治疗胆囊结石合并胆总管结石的一种重要的方法。从解剖上说，胆囊管一般长度约2.5～4.0 cm，直径0.20～0.35 cm，胆囊内的小结石易通过较粗的胆囊管进入胆总管。因此，理论上只要胆道镜能够通过胆囊管进入胆总管，便可将胆总管结石取出。但腹腔镜下胆道镜操作较开腹手术经窦道胆道镜探查取石的难度大，操作困难，取石成功率与患者的自身状况、胆道镜的粗细质地以及术者的经验有很大关系。国内外多项报道[6-9]显示LTCBDE的成功率为70%～96%。由于LTCBDE治疗胆囊结石合并胆总管结石的方法符合一次性完成、胆管Ⅰ期缝合、保留括约肌功能等的标准，被很多学者在腹腔镜治疗胆囊结石合并胆总管结石时推崇[8,10]。本研究52例患者中40例顺利完成手术，其余患者因胆囊管过细无法进胆道镜而改为其他方式手术。43例患者一次取石成功，占82.69%。分析本研究取石成功率不高的原因，考虑和术前病例选择、术中经胆囊管进入胆道镜的技巧不高、胆道取石方法不熟练等有关，这也是日后需要认真总结改进之处。结合相关文献报道[7，11]和手术经验，笔者认为对于结石少于3枚且直径<0.5 cm的继发性胆总管结石、胆囊管直径>0.4 cm、MRCP检查提示胆囊管无明显狭窄及闭塞，无Mirizzi综合征表现的胆囊结石合并胆总管结石的患者，行LTCBDE成功率较高。

笔者的手术经验为：(1)尽量游离胆囊管至汇合部，可于胆囊管切开处缝合牵引线，配合术中牵拉胆囊协助胆道镜经胆囊管切开处进入胆总管。(2)可采用球囊扩张胆囊管松弛胆囊管壁，增加胆道镜经胆囊管进镜机会，尤其适用于炎症增厚、管腔狭窄的胆囊管。(3)对于经胆囊管进胆道镜困难的患者，可采用胆囊管汇入胆总管部微切开的途径[12]，经切开处置入胆道镜取出胆总管结石。若患者术前无急性胆管炎、重度黄疸、胆总管下端水肿，也可考虑Ⅰ期缝合胆囊管汇入胆总管部切开处，最大限度为患者提供微创治疗方法[13]。(4)对于胆总管内较大的结石可以采用取石网篮将其夹碎后取出，或联合碎石设备将其粉碎后取出。(5)尽量减少反复插管，轻柔操作，避免过度刺激胆总管壁及十二直肠乳头导致Oddi括约肌水肿或痉挛，从而增加术后胆漏风险。(6)在对胆管壁进行缝合时，避免针距过小，张力过大，导致胆管壁缺血坏死。手术结束前常规用白色纱条检查有无漏胆，常规于Winslow孔放置腹腔引流管，以便观察及治疗患者术后可能出现的胆漏。本研究患者1例行腹腔镜下胆总管切开取石术后出现胆漏，经保守治疗后康复，未导致严重后果。所有患者术后随访1年，均未见胆总管结石复发。

综上所述，经胆囊管途径行胆道探查微创优势明显，手术创伤小、安全、有效，患者恢复快，是治疗胆囊结石合并胆总管结石的一种重要手术方式。在经胆囊管进行胆道探查取石时，应综合考虑患者胆囊管直径、胆总管结石大小及数目、胆道镜直径等条件，严格掌握其适应证，提高手术成功率。

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引证本文：LIANG G, MA FP, HE MG. Clinical analysis of laparoscopic combined with choledochoscope via the cystic duct for choledocholithiasis[J]. J Clin Hepatol, 2017, 33(11): 2170-2172. (in Chinese)

梁刚， 马富平， 何盟国. 腹腔镜联合胆道镜经胆囊管治疗胆囊结石合并胆总管结石的临床分析[J]. 临床肝胆病杂志, 2017, 33(11): 2170-2172.

(本文编辑：葛 俊)

Clinicalanalysisoflaparoscopiccombinedwithcholedochoscopeviathecysticductforcholedocholithiasis

LIANGGang,MAfuping,HEmengguo.

(1.DepartmentofHepatobiliarySurgery,Xianyang215HospitaloftheNuclearIndustryinShaanxiProvince,Xianyang,Shaanxi712000,China)

ObjectiveTo explore the clinical application of laparoscopic transcystic common bile duct exploration.MethodsFrom Jan 2014 to Dec 2015, laparoscopic transcystic common bile duct exploration was performed in 52 cases of cholecystolithiasis. The therapeutic effects of cases were studied.ResultsAmong them, 40 cases were performed operation successfully.The success rate of operation was 76.92%. 7 cases were changed to laparoscopic common bile duct incision exploratory stone operation. 5 cases were performed common bile duct incision nephrolithotomy,and the transfer rate was 9.62%. 43 cases were toke stone success at a time in all of patients. The success removed rate was 82.69%. The last 9 patients included 8 cases performed laparoscopic transcystic common bile duct exploration and 1 case performed laparoscopic common bile duct incision exploratory stone operation. All cases were placed abdominal cavity drainage tube pulled out after 3-10 days. Biliary leakage occurred in 1 patients performed laparoscopic common bile duct incision exploratory stone operation, and it was cured after conservative treatment. No biliary tract infection, biliary tract bleeding complications occurred. The average hospitalization time was (8.24±2.52) days. All patients were followed up 1 year. No extrahepatic bile duct stones were found by B-ultrasonic and MRCP, and bilirubin were normal.ConclusionLaparoscopic transcystic common bile duct exploration has positive clinical efficacy with small trauma, quick rever , less complications, safety and effective.etc. But its indications must be grasped strictly in clinical promotion.

cholecystolithiasis; choledocholithiasis; laparoscopy; choledochoscope; therapy

R657.42

A

1001-5256(2017)11-2170-03

10.3969/j.issn.1001-5256.2017.11.024

2017-05-12；

2017-07-13。

梁刚(1985-)，男，主治医师，主要从事肝胆外科疾病治疗方面的研究。

马富平，电子信箱: mfp71@sina.com。