Surgeries for benign diseases of the extrahepatic bile duct(EHBD) are classified as lithotomy(i.e., choledocholithotomy) or diversion(i.e.,choledochojejunostomy). Because of technical challenges, laparoscopic approach...Surgeries for benign diseases of the extrahepatic bile duct(EHBD) are classified as lithotomy(i.e., choledocholithotomy) or diversion(i.e.,choledochojejunostomy). Because of technical challenges, laparoscopic approaches for these surgeries have not gained worldwide popularity. The right upper quadrant of the abdomen is advantageous for laparoscopic procedures,and laparoscopic choledochojejunostomy is safe and feasible. Herein, we summarize tips and pitfalls in the actual procedures of choledocholithotomy.Laparoscopic choledocholithotomy with primary closure of the transductal incision and transcystic C-tube drainage has excellent clinical outcomes;however, emergent biliary drainage without endoscopic sphincterotomy and preoperative removal of anesthetic risk factors are required. Elastic suture should never be ligated directly on the cystic duct. Interrupted suture placement is the first choice for hemostasis near the EHBD. To prevent progressive laceration of the EHBD, full-layer interrupted sutures are placed at the upper and lower edges of the transductal incision. Cholangioscopy has only two-way operation; using dedicated forceps to atraumatically grasp the cholangioscope is important for smart maneuvering. The duration of intraoperative stone clearance accounts for most of the operative time. Moreover, dedicated forceps are an important instrument for atraumatic grasping of the cholangioscope. Damage to the cholangioscope requires expensive repair. Laparoscopic approach for choledocholithotomy involves technical difficulties. I hope this document with the visual explanation and literature review will be informative for skillful surgeons.展开更多
目的探讨分层缝合技术在两孔腹腔镜胆囊切除术+胆总管切开取石术中的应用价值。方法 2014年8月至2017年8月,对宁波市医疗中心李惠利医院267例胆总管结石患者施行两孔腹腔镜胆囊切除术+胆总管切开取石术,并进行前瞻性研究。267例中,110...目的探讨分层缝合技术在两孔腹腔镜胆囊切除术+胆总管切开取石术中的应用价值。方法 2014年8月至2017年8月,对宁波市医疗中心李惠利医院267例胆总管结石患者施行两孔腹腔镜胆囊切除术+胆总管切开取石术,并进行前瞻性研究。267例中,110例采用分层缝合技术,157例采用单层缝合技术。比较两组手术时间、术后住院时间和术后并发症。结果两组均顺利完成手术,无一例中转开腹。两组手术时间没有明显差异(t=-0.587,P=0.086)。分层缝合组术后住院时间和术后胆漏的发生率明显低于单层缝合组[(7.6±1.8)d vs (5.8±1.7)d,t=2.776,P<0.001;4.5%(5/110) vs 20.4%(32/157),χ~2=13.590,P<0.001]。在单层缝合组中,合并急性胆管炎患者的术后胆漏率明显高于无急性胆管炎患者[44.4%(12/27)vs 15.4%(20/130),χ~2=11.634,P=0.001];在分层缝合组中,有无重症胆管炎对患者术后胆漏的发生率不存在明显影响[11.8%(2/17) vs 3.2%(3/93),χ~2=0.848,P=0.357]。结论采用分层缝合技术在两孔腹腔镜胆囊切除术+胆总管切开取石术中是可行且安全的,其优点是减少了胆管的渗漏,缩短了住院时间。展开更多
文摘Surgeries for benign diseases of the extrahepatic bile duct(EHBD) are classified as lithotomy(i.e., choledocholithotomy) or diversion(i.e.,choledochojejunostomy). Because of technical challenges, laparoscopic approaches for these surgeries have not gained worldwide popularity. The right upper quadrant of the abdomen is advantageous for laparoscopic procedures,and laparoscopic choledochojejunostomy is safe and feasible. Herein, we summarize tips and pitfalls in the actual procedures of choledocholithotomy.Laparoscopic choledocholithotomy with primary closure of the transductal incision and transcystic C-tube drainage has excellent clinical outcomes;however, emergent biliary drainage without endoscopic sphincterotomy and preoperative removal of anesthetic risk factors are required. Elastic suture should never be ligated directly on the cystic duct. Interrupted suture placement is the first choice for hemostasis near the EHBD. To prevent progressive laceration of the EHBD, full-layer interrupted sutures are placed at the upper and lower edges of the transductal incision. Cholangioscopy has only two-way operation; using dedicated forceps to atraumatically grasp the cholangioscope is important for smart maneuvering. The duration of intraoperative stone clearance accounts for most of the operative time. Moreover, dedicated forceps are an important instrument for atraumatic grasping of the cholangioscope. Damage to the cholangioscope requires expensive repair. Laparoscopic approach for choledocholithotomy involves technical difficulties. I hope this document with the visual explanation and literature review will be informative for skillful surgeons.
文摘目的探讨分层缝合技术在两孔腹腔镜胆囊切除术+胆总管切开取石术中的应用价值。方法 2014年8月至2017年8月,对宁波市医疗中心李惠利医院267例胆总管结石患者施行两孔腹腔镜胆囊切除术+胆总管切开取石术,并进行前瞻性研究。267例中,110例采用分层缝合技术,157例采用单层缝合技术。比较两组手术时间、术后住院时间和术后并发症。结果两组均顺利完成手术,无一例中转开腹。两组手术时间没有明显差异(t=-0.587,P=0.086)。分层缝合组术后住院时间和术后胆漏的发生率明显低于单层缝合组[(7.6±1.8)d vs (5.8±1.7)d,t=2.776,P<0.001;4.5%(5/110) vs 20.4%(32/157),χ~2=13.590,P<0.001]。在单层缝合组中,合并急性胆管炎患者的术后胆漏率明显高于无急性胆管炎患者[44.4%(12/27)vs 15.4%(20/130),χ~2=11.634,P=0.001];在分层缝合组中,有无重症胆管炎对患者术后胆漏的发生率不存在明显影响[11.8%(2/17) vs 3.2%(3/93),χ~2=0.848,P=0.357]。结论采用分层缝合技术在两孔腹腔镜胆囊切除术+胆总管切开取石术中是可行且安全的,其优点是减少了胆管的渗漏,缩短了住院时间。
