沿“胆囊管”逆行追踪法在预防腹腔镜胆囊切除术肝外胆管损伤中的应用价值
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摘要
目的:探讨沿"胆囊管"逆行追踪法预防腹腔镜胆囊切除术(LC)中胆管损伤(BDI)可行性和有效性。方法:选择2018年3月—2018年10月324例行LC的患者,患者术中均采用沿"胆囊管"逆行追踪法,即在分离出认为的"胆囊管"后,紧贴该"胆囊管"向胆囊方向逆行游离,如游离后证实为真胆囊管,即可断夹,并切除胆囊,否则改变解剖路径,重新寻找胆囊管,以避免BDI,直至胆囊切除。结果:324例患者中,319例"胆囊管"证实为实际胆囊管或其安全部位,3例发现实际为肝(胆)总管,2例为变异的肝外右后叶胆管汇入胆囊管。所有患者均顺利完成LC,平均手术时间64.3(25～210)min,平均出血量7.3(2～150)mL。术后并发轻微胆汁漏、胆囊区少量积液1例,穿刺孔感染2例,经穿刺引流、伤口换药而愈。其余患者未发现BDI。平均术后住院时间2.6(1～13)d。随访1个月未见黄疸、腹痛等异常。结论:沿"胆囊管"逆行追踪法预防LC术中BDI安全有效、操作简便,可作为其他预防方法的补充。
Objective: To investigate the feasibility and efficacy of retrograde tracing along the cystic duct to prevent bile duct injury(BDI) during laparoscopic cholecystectomy(LC). Methods: Three hundred and twenty-four patients undergoing LC were selected. The approach of retrograde tracing along the cystic duct was performed in all patients during operation, namely, after the supposed cystic duct was isolated, retrograde dissection closely along this duct toward the gallbladder was performed, and if this duct was verified to be the true cystic duct, it was clamped and then cholecystectomy was performed, but if this was not the cystic duct, the anatomical pathway was changed to seek the cystic duct for prevention of BDI up to the completion of cholecystectomy.Results: Of the 324 patients, the supposed cystic duct was verified to be the actual cystic duct or its safety site in 319 cases, was found actually to be the common hepatic(bile) duct in 3 cases, and aberrant right posterior hepatic duct opening into the cystic duct in 2 cases. LC was uneventfully performed in all the 324 patients. The average operative time was 64.3(25–210) min, and the average blood loss was 7.3(2–150) mL.Postoperative minor bile leakage and fluid collections in the gallbladder region occurred in one patient, which were cured by puncture drainage and wound dressing. No BDI was found in the other patients. The average length of postoperative stay was 2.6(1–13) d. No jaundice or abdominal pain was noted in the patients during one-moth follow-up.Conclusion: Retrograde tracing along the cystic duct for prevention of BDI during LC is safe and reliable as well as easy to perform. It can be used as a supplement to other preventive methods.
Objective: To investigate the feasibility and efficacy of retrograde tracing along the cystic duct to prevent bile duct injury(BDI) during laparoscopic cholecystectomy(LC). Methods: Three hundred and twenty-four patients undergoing LC were selected. The approach of retrograde tracing along the cystic duct was performed in all patients during operation, namely, after the supposed cystic duct was isolated, retrograde dissection closely along this duct toward the gallbladder was performed, and if this duct was verified to be the true cystic duct, it was clamped and then cholecystectomy was performed, but if this was not the cystic duct, the anatomical pathway was changed to seek the cystic duct for prevention of BDI up to the completion of cholecystectomy.Results: Of the 324 patients, the supposed cystic duct was verified to be the actual cystic duct or its safety site in 319 cases, was found actually to be the common hepatic(bile) duct in 3 cases, and aberrant right posterior hepatic duct opening into the cystic duct in 2 cases. LC was uneventfully performed in all the 324 patients. The average operative time was 64.3(25–210) min, and the average blood loss was 7.3(2–150) mL.Postoperative minor bile leakage and fluid collections in the gallbladder region occurred in one patient, which were cured by puncture drainage and wound dressing. No BDI was found in the other patients. The average length of postoperative stay was 2.6(1–13) d. No jaundice or abdominal pain was noted in the patients during one-moth follow-up.Conclusion: Retrograde tracing along the cystic duct for prevention of BDI during LC is safe and reliable as well as easy to perform. It can be used as a supplement to other preventive methods.
引文
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[16]Singh M,Prasad N.The anatomy of Rouviere's sulcus as seen during laparoscopic cholecystectomy:A proposed classification[J].J Minim Access Surg,2017,13(2):89-95.doi:10.4103/0972-9941.201731.
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[19]杨晓平,万亚峰,周立新,等.避免腹腔镜胆囊切除术中胆管损伤的手术技巧[J].肝胆胰外科杂志,2016,28(3):185-187.doi:10.11952/j.issn.1007-1954.2016.03.003.Yang XP,Wan YF,Zhou LX,et al.Surgical skills of avoiding bile duct injury in laparoscopic cholecystectomy[J].Journal of Hepatopancreatobiliary Surgery,2016,28(3):185-187.doi:10.11952/j.issn.1007-1954.2016.03.003.
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[21]Dili A,Bertrand C.Laparoscopic ultrasonography as an alternative to intraoperative cholangiography during laparoscopic cholecystectomy[J].World J Gastroenterol,2017,23(29):5438-5450.doi:10.3748/wjg.v23.i29.5438.
[22]Ding GQ,Cai W,Qin MF.Is intraoperative cholangiography necessary during laparoscopic cholecystectomy for cholelithiasis?[J].World J Gastroenterol,2015,21(7):2147-2151.doi:10.3748/wjg.v21.i7.2147.
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[24]Photi ES,El-Hadi A,Brown S,et al.The Routine Use of Cholangiography for Laparoscopic Cholecystectomy in the Modern Era[J].JSLS,2017,21(3).pii:e2017.00032.doi:10.4293/JSLS.2017.00032.
[25]Graves C,Ely S,Idowu O,et al.Direct Gallbladder Indocyanine Green Injection Fluorescence Cholangiography During Laparoscopic Cholecystectomy[J].J Laparoendosc Adv Surg Tech A,2017,27(10):1069-1073.doi:10.1089/lap.2017.0070.
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[2]Kohn JF,Trenk A,Kuchta K,et al.Characterization of common bile duct injury after laparoscopic cholecystectomy in a high-volume hospital system[J].Surg Endosc,2018,32(3):1184-1191.doi:10.1007/s00464-017-5790-8.
[3]李永研,李延甫,郭树军,等.腹腔镜胆囊切除术胆管损伤的防治[J].腹腔镜外科杂志,2002,7(3):153-154.doi:10.3969/j.issn.1009-6612.2002.03.011.Li YY,Li YF,Guo SJ,et al.Prevention and treatment of bile duct injury in laparoscopic cholecystectomy[J].Journal of Laparoscopic Surgery,2002,7(3):153-154.doi:10.3969/j.issn.1009-6612.2002.03.011.
[4]Way LW,Stewart L,Gantert W,et al.Causes and prevention of laparoscopic bile duct injuries:analysis of 252 cases from a human factors and cognitive psychology perspective[J].Ann Surg,2003,237(4):460-469.doi:10.1097/01.SLA.0000060680.92690.E9.
[5]戴海粟,陈志宇.肝门部解剖变异与腹腔镜胆囊切除术中胆管损伤[J].中华普通外科杂志,2017,32(8):661-664.doi:10.3760/cma.j.issn.1007-631X.2017.08.008.Dai HS,Chen ZY.Anatomic variations of the hepatic portal region and bile duct injury in laparoscopic cholecystectomy[J].Zhong Hua Pu Tong Wai Ke Za Zhi,2017,32(8):661-664.doi:10.3760/cma.j.issn.1007-631X.2017.08.008.
[6]Cai XJ,Ying HN,Yu H,et al.Blunt Dissection:A Solution to Prevent Bile Duct Injury in Laparoscopic Cholecystectomy[J].Chin Med J(Engl),2015,128(23):3153-3157.doi:10.4103/0366-6999.170270.
[7]朱建平,牟东成,薛晨辉,等.急性胆囊炎胆囊颈管结石嵌顿的腹腔镜胆囊切除术[J].中国现代手术学杂志,2018,22(1):10-13.doi:10.16260/j.cnki.1009-2188.2018.01.003.Zhu JP,Mou DC,Xue CH,et al.Experiences of Emergency Laparoscopic Cholecystectomy for Acute Cholecystitis Patients with Gallstone Incarcerated in Cervical Cystic Ducts[J].Chinese Journal of Modern Operative Surgery,2018,22(1):10-13.doi:10.16260/j.cnki.1009-2188.2018.01.003.
[8]华伟,梁志宏,刘书强,等.经后入路解剖胆囊管切除胆囊在腹腔镜胆囊切除术中的应用[J].中国实用医药,2018,13(20):26-27.doi:10.14163/j.cnki.11-5547/r.2018.20.011.Hua W,Liang ZH,Liu SQ,et al.Application of dissect cystic duct to surgical remove bile cyst in laparoscopic cholecystectomy by posterior approach[J].China Practical Medical,2018,13(20):26-27.doi:10.14163/j.cnki.11-5547/r.2018.20.011.
[9]陈光彬,刘丹峰,章新桥,等.Rouviere沟引导的胆囊后三角入路在预防腹腔镜胆囊切除术中胆管损伤的作用[J].中华普通外科杂志,2018,33(2):101-104.doi:10.3760/cma.j.issn.1007-631X.2018.02.002.Chen GB,Liu DF,Zhang XQ,et al.Role of Rouviere's sulcus in relation to posterior cystohepatic triangle in prevention of bile duct injury in laparoscopic cholecystectomy[J].Zhong Hua Pu Tong Wai Ke Za Zhi,2018,33(2):101-104.doi:10.3760/cma.j.issn.1007-631X.2018.02.002.
[10]Sewefy AM,Hassanen AM,Atyia AM,et al.Retroinfundibular laparoscopic cholecystectomy versus standard laparoscopic cholecystectomy in difficult cases[J].Int J Surg,2017,43:75-80.doi:10.1016/j.ijsu.2017.05.044.
[11]Honda G,Hasegawa H,Umezawa A.Universal safe procedure of laparoscopic cholecystectomy standardized by exposing the inner layer of the subserosal layer(with video)[J].J Hepatobiliary Pancreat Sci,2016,23(9):E14-19.doi:10.1002/jhbp.382.
[12]Strasberg SM,Hertl M,Soper NJ.An analysis of the problem of biliary injury during laparoscopic cholecystectomy[J].J Am Coll Surg,1995,180(1):101-125.
[13]Nijssen MA,Schreinemakers JM,van der Schelling GP,et al.Improving Critical View of Safety in Laparoscopic Cholecystectomy by Teaching Interventions[J].J Surg Educ,2016,73(3):442-447.doi:10.1016/j.jsurg.2015.11.015.
[14]Hugh TB.New strategies to prevent laparoscopic bile duct injury--surgeons can learn from pilots[J].Surgery,2002,132(5):826-835.doi:10.1067/msy.2002.127681.
[15]Peti N,Moser MA.Graphic reminder of Rouviere's sulcus:a useful landmark in cholecystectomy[J].ANZ J Surg,2012,82(5):367-368.doi:10.1111/j.1445-2197.2012.06032.x.
[16]Singh M,Prasad N.The anatomy of Rouviere's sulcus as seen during laparoscopic cholecystectomy:A proposed classification[J].J Minim Access Surg,2017,13(2):89-95.doi:10.4103/0972-9941.201731.
[17]Lockhart S,Singh-Ranger G.Rouviere's sulcus-Aspects of incorporating this valuable sign for laparoscopic cholecystectomy[J].Asian J Surg,2018,41(1):1-3.doi:10.1016/j.asjsur.2016.07.012.
[18]Townsend CM Jr,Beauchamp RD,Evers BM,et al.Sabiston textbook of surgery[M].Hernias.Elsevier/Saunders,Philadelphia,2004:1600.
[19]杨晓平,万亚峰,周立新,等.避免腹腔镜胆囊切除术中胆管损伤的手术技巧[J].肝胆胰外科杂志,2016,28(3):185-187.doi:10.11952/j.issn.1007-1954.2016.03.003.Yang XP,Wan YF,Zhou LX,et al.Surgical skills of avoiding bile duct injury in laparoscopic cholecystectomy[J].Journal of Hepatopancreatobiliary Surgery,2016,28(3):185-187.doi:10.11952/j.issn.1007-1954.2016.03.003.
[20]Machi J,Johnson JO,Deziel DJ,et al.The routine use of laparoscopic ultrasound decreases bile duct injury:a multicenter study[J].Surg Endosc,2009,23(2):384-388.doi:10.1007/s00464-008-9985-x.
[21]Dili A,Bertrand C.Laparoscopic ultrasonography as an alternative to intraoperative cholangiography during laparoscopic cholecystectomy[J].World J Gastroenterol,2017,23(29):5438-5450.doi:10.3748/wjg.v23.i29.5438.
[22]Ding GQ,Cai W,Qin MF.Is intraoperative cholangiography necessary during laparoscopic cholecystectomy for cholelithiasis?[J].World J Gastroenterol,2015,21(7):2147-2151.doi:10.3748/wjg.v21.i7.2147.
[23]T?rnqvist B,Str?mberg C,Akre O,et al.Selective intraoperative cholangiography and risk of bileduct injury during cholecystectomy[J].Br J Surg,2015,102(8):952-958.doi:10.1002/bjs.9832.
[24]Photi ES,El-Hadi A,Brown S,et al.The Routine Use of Cholangiography for Laparoscopic Cholecystectomy in the Modern Era[J].JSLS,2017,21(3).pii:e2017.00032.doi:10.4293/JSLS.2017.00032.
[25]Graves C,Ely S,Idowu O,et al.Direct Gallbladder Indocyanine Green Injection Fluorescence Cholangiography During Laparoscopic Cholecystectomy[J].J Laparoendosc Adv Surg Tech A,2017,27(10):1069-1073.doi:10.1089/lap.2017.0070.
[26]Zroback C,Chow G,Meneghetii A,et al.Fluorescent cholangiography in laparoscopic cholecystectomy:the initial Canadian experience[J].Am J Surg,2016,211(5):933-937.doi:10.1016/j.amjsurg.2016.01.013.
[27]Ankersmit M,van Dam DA,van Rijswijk AS,et al.Fluorescent Imaging With Indocyanine Green During Laparoscopic Cholecystectomy in Patients at Increased Risk of Bile Duct Injury[J].Surg Innov,2017,24(3):245-252.doi:10.1177/1553350617690309.
[28]周红兵,杨兴业,陈曦,等.腹腔镜下胆囊动脉入路精细解剖胆囊三角的临床价值[J].中国普通外科杂志,2015,24(8):1121-1124.doi:10.3978/j.issn.1005-6947.2015.08.013.Zhou HB,Yang XY,Chen X,et al.Clinical value of laparoscopic meticulous dissection of Calot's triangle via cystic artery approach[J].Chinese Journal of General Surgery,2015,24(8):1121-1124.doi:10.3978/j.issn.1005-6947.2015.08.013.
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