自制腹腔镜胆道冲洗器在腹腔镜胆总管取石术中的应用：双中心经验总结

Application of self-designed laparoscopic bile duct irrigator in laparoscopic common bile duct exploration: a two-center experience

摘要:

背景与目的 腹腔镜胆总管探查取石术（LCBDE）是治疗胆总管结石的主要治疗方式，但在LCBDE过程中，由于术中缺少窦道支撑，经典的胆道镜下网篮取石相对较为困难，对术者的操作技术要求高，反复的胆道镜取石也容易造成胆道镜损坏或胆管壁损伤。为了更好地提高取石效率，降低手术难度，笔者对胆道镜取石术进行改良，即LCBDE术中采用自制腹腔镜胆道冲洗器配合胆道镜取石。本研究总结两个中心应用该方法的临床效果。方法 回顾2017年1月—2021年1月福建省立医院和福建省浦城县医院收治的313例LCBDE术中应用自制腹腔镜胆道冲洗器治疗的胆总管结石患者的临床资料，分析患者围手术期情况及近期预后。结果 313例患者中，男132例，女181例；平均年龄（56.3±13.2）岁；173例患者为胆总管单发结石，140例患者为胆总管多发结石（结石最多者为10枚）；中位结石直径为0.5（0.2~3.1） cm，中位胆总管直径为1.2（0.6~3.3）cm。手术均顺利完成，无中转开腹。其中281例（89.8%）患者使用自制腹腔镜胆道冲洗器取净结石，32例（10.2%）患者术中联合网篮取石。307例（98.1%）患者一期取净结石，6例（1.9%）患者残留结石；157例（50.2%）术后一期缝合胆总管，156例（49.8%）术后留置T管引流。平均手术时间（109.3±29.4）min，平均术中出血量（42.5±8.4）mL，平均术后住院时间（7.6±3.2）d。术后12例出现胆汁漏，12例出现腹腔感染，9例出现肺部感染，7例出现切口感染，1例出现术后出血，均经保守治疗后痊愈。6例无法一期取净结石患者均于术后1.5个月行经T管窦道胆道镜取净结石。术后随访6~12个月，无胆管结石复发、胆道狭窄等其他并发症。结论 LCBDE术中应用自制腹腔镜胆道冲洗器安全可靠，取石效率高，故推荐使用。

Abstract:

Background and Aims Laparoscopic common bile duct exploration (LCBDE) is the main method for the treatment of common bile duct stones. However, due to the lack of sinus tract support, the traditional laparoscopic choledocholithotomy using basket forceps under choledochoscopic guidance is relatively difficult with high technical requirement. Repeated stone extraction may easily cause the damage of the choledochoscopy or injury of the bile duct wall. For the purpose of achieving a high stone extraction rate and low technical requirement, the authors modified the choledochoscopic stone removal procedure by using a self-designed laparoscopic bile duct irrigator to assist choledochoscopic lithotripsy during LCBDE. This study was conducted to summarize the clinical effect of using this method in two centers.Methods The clinical data of 313 eligible patients with common bile duct stones treated with self-designed laparoscopic bile duct irrigator during LCBDE in Fujian Provincial Hospital and Fujian Pucheng County Hospital from January 2017 to January 2021 were reviewed. The perioperative data and short-term outcomes of the patients were analyzed.Results Of the 313 patients, 132 cases were males and 181 cases were females with a mean age of (56.3±13.2) years, 173 cases had solitary stone and 140 patients had multiple stones (the maximum number of stone amount was 10); The median diameter of the stones was 0.5 (0.2-3.1) cm and the median common bile duct diameter was 1.2 (0.6-3.3) cm. All the 313 cases were successfully performed without conversion to open surgery. The stones were completely removed by laparoscopic bile duct irrigator in 281 cases (89.8%), and in 32 cases were extracted in combination with a stone basket. The stones were completely removed in one session in 307 patients (98.1%) while residual stones were found in 6 patients; 157 patients received primary closure and 156 patients underwent T-tube drainage of the common bile duct after operation. The mean operative time was (109.3±29.4) min, the mean intraoperative blood loss amount was (42.5±8.4) mL, and the average length of postoperative hospital stay was (7.6±3.2) d. There were 12 cases of bile leakage, 12 cases of abdominal infection, 9 cases of pulmonary infection, 7 cases of incision infection, and 1 case of postoperative bleeding after operation. All of them were cured after non-surgical approach. The residual stones in all the 6 patients with failure of complete stone removal in the first session were completely cleared by choledochoscopic lithotripsy through the T-tube tract 1.5 months after the operation. Postoperative follow-up was conducted for 6 to 12 months, and no recurrent bile duct stones and biliary stenosis or other complications were noted.Conclusion Using self-designed laparoscopic bile duct irrigator in LCBDE is safe and reliable with high efficiency. It is recommended to be used.