有胆道手术史患者的腹腔镜胆总管探查
Summary
基于手术方法和解剖标志物的程序化手术有助于缩短手术时间，减少并发症，并提高手术的安全性。本研究对有胆道手术史的患者腹腔镜胆总管探查的手术方法及解剖标志物进行了调查和总结。
Abstract
对于复发性胆总管结石，既往手术中的腹部粘连会导致解剖结构发生变化，并且在进行腹腔镜胆总管探查（LCBDE）的另一次手术时容易发生继发性损伤，这曾经被认为是相对禁忌症。鉴于目前手术技术的局限性，本研究总结了LCBDE再次手术的手术方法和关键解剖标志。提出了4种普通外科方法暴露胆总管，包括黄皮韧带入路、肝十二指肠前韧带入路、右肝十二指肠韧带入路和混合入路。此外，这项研究还强调了七个关键的解剖标志：顶腹膜、胃肠道浆膜、肝韧带、肝下缘、胃窦、十二指肠和结肠肝弯曲，有助于安全地分离腹膜粘连并暴露胆总管。此外，为了缩短胆总管取石术的时间，创新性地采用顺序方法去除胆总管结石。掌握上述手术方法，包括识别关键解剖标志和采用序贯法，将提高LCBDE再次手术的安全性，缩短手术时间，促进患者快速康复，减少术后并发症，有助于该技术的推广应用。
Introduction
胆总管结石是最常见的胆道疾病之一，复发率高1。由于复发性胆总管结石通常涉及多块结石，再加上内镜逆行胰胆管造影术 （ERCP）/内镜括约肌切开术 （EST） 可能会损害 Oddi 括约肌的功能并导致反复逆行胆道感染，因此复发性胆总管结石患者通常需要两次或两次以上的外科手术2。
随着微创手术的普及和腹腔镜技术的进步，腹腔镜胆总管探查术（LCBDE）凭借创伤小、恢复快、保留Oddi括约肌功能等优点，在临床上得到了广泛的应用。复发性胆总管结石患者的腹部粘连导致解剖结构改变，因此这些患者在随后的胆管探查中容易发生继发性损伤。因此，腹腔粘连被认为是腹腔镜手术的禁忌症4，5。随着技术的进一步发展，LCBDE已被初步证实在有胆道手术史的患者中是可行的6，7，8。
然而，相关研究有限，仍需要对这种手术技术进行更深入的研究。LCBDE的编程操作通常缺乏，特别是对于有广泛腹部粘连的患者。基于这种情况，本研究旨在通过调查LCBDE在有胆道手术史的患者中的手术方法和解剖标志来开发一种程序化程序。基于手术方法和解剖标志的程序化手术可以帮助缩短手术时间，减少并发症并提高手术安全性9，10。
Protocol
共纳入177例在2010年9月至2021年12月期间接受LCBDE的有胆道手术史的患者。本研究获得暨南大学附属第一医院机构评审委员会的批准。所有患者均提供了书面知情同意书。 1. 入选标准 包括胆总管 （CBD） 中有两个以上结石的患者。 包括总直径为 ≥20 毫米的 CBD 结石患者。 包括 CBD 直径为 ≥10 毫米的患者。 2. 排除?…
Representative Results
这项研究包括177名患者（平均年龄：61.74±5.97岁），包括79名男性和98名女性。共有69例患者有开放性胆囊切除术（OC）病史;36例患者有OC和开放性胆总管探查（OCBDE）病史;8例患者有OC、OCBDE和左叶肝切除术（LLH）病史;3例患者有OC、OCBDE和胆总管空肠吻合术史;42例患者有腹腔镜胆囊切除术（LC）病史;7例患者有LC和LCBDE病史;12例患者有LC和OCBDE病史（表1）。 共有174例患者…
Discussion
胆总管结石最常见的原因是结石通过胆囊落入 CBD，而一些 CBD 结石可能来自 CBD 本身1。胆总管结石患者胆总管结石的发生率为10%-18%，4%-24%的胆总管结石患者在第一次截石术后复发，常需重复手术12，13。自1991年LCBDE首次应用以来，它已被证明对治疗胆总管结石是安全有效的，并且由于手术可以在一个阶段完成，因此得到了广泛的接受和…
Divulgations
The authors have nothing to disclose.
Acknowledgements
这项工作得到了广东省医学科学研究基金（编号：A2021091）、中央高校基础研究费专项（编号21622312）、广州市基础研究计划基础与应用基础研究项目（编号：2023A04J01111）、暨南大学附属第一医院普外科旗舰专科建设项目（编号：711003）的资助。 暨南大学附属顺德医院科研发展专项基金（202101004号）。
Materials
| Electronic choledochoscope | Olympus | CHF-V | / |
| Harmonic scalpel | Ethcion | HAR36 | / |
| Stone basket | Cook | NTSE-045065-UDH | / |
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Tags
Laparoscopic Common Bile Duct ExplorationLCBDEBiliary Tract SurgerySurgical ApproachesAnatomical LandmarksHepatic Round Ligament ApproachAnterior Hepatoduodenal Ligament ApproachRight Hepatoduodenal Ligament ApproachHybrid ApproachAdhesion SeparationParietal PeritoneumGastrointestinal CirrhosaTractionBlunt DissectionUltrasonic ScalpelScissors
Citer Cet Article
Liang, J., Li, J., Jiang, Y., Li, Q., Liu, Z., Xiang, L., Hu, Y., Cao, M. Laparoscopic Common Bile Duct Exploration in Patients with a Previous History of Biliary Tract Surgery. J. Vis. Exp. (192), e64888, doi:10.3791/64888 (2023).