Azagra J S, De Simone P, Goergen M
Service de Chirurgie Digestive et Laparoscopique, CHU André Vésale, Montigny-Le-Tilleul, Belgium.
World J Surg. 2001 Oct;25(10):1331-4. doi: 10.1007/s00268-001-0119-z.
Despite its minimal invasiveness, laparoscopic cholecystectomy (LC) carries unquestionably higher morbidity and mortality rates when compared with the open counterpart (OC). Among the iatrogenic injuries, biliary tract lesions are the most clinically relevant because of their potential for patient's disability and long-term sequelae. No universal agreement exists for classifying these lesions, but numerous authors have advocated a distinction between bile leaks and bile injuries. Even if not entirely correct, bile leaks refer to fistulas from minor ducts in continuity with the major ductal system or from accessory ducts (as the duct of Luschka). Biliary injuries are major complications consisting of leaks, strictures, transection, or ligation of major bile ducts. While bile leaks are typically treated by percutaneous and/or endoscopic drainage and stenting, biliary injuries often require a combined radiology-assisted and endoscopic approach or even conventional surgery. The role of laparoscopy in the management algorithm of biliary lesions is still anecdotal. To date, a total of 25 cases of laparoscopic drainage of post-cholecystectomy bilomas have been reported in the literature, whereas there is no mention of laparoscopic primary repair of biliary injuries detected at or after cholecystectomy. The main reasons depend on the excellent results achieved by the ancillary techniques; the emergency settings that accompany more complex biliary lesions; the technical challenges posed by the presence of inflammation, collections, and obscured anatomy; and the potential for malpractice litigation. However, a sound laparoscopic technique and a strict adherence to basic surgical tenets are crucial in order to avoid the incidence of iatrogenic biliary injuries and reduce their still unknown impact on long-term patient disability.
尽管腹腔镜胆囊切除术(LC)具有微创性,但与开腹胆囊切除术(OC)相比,其发病率和死亡率无疑更高。在医源性损伤中,胆道病变因其可能导致患者残疾和长期后遗症而在临床上最为相关。对于这些病变的分类尚无普遍共识,但许多作者主张区分胆漏和胆管损伤。即使不完全准确,胆漏是指与主要胆管系统连续的小胆管或副胆管(如Luschka管)形成的瘘管。胆管损伤是主要并发症,包括主要胆管的漏、狭窄、横断或结扎。虽然胆漏通常通过经皮和/或内镜引流及支架置入治疗,但胆管损伤往往需要联合放射学辅助和内镜方法,甚至传统手术。腹腔镜在胆管病变处理流程中的作用仍不明确。迄今为止,文献中总共报道了25例腹腔镜引流胆囊切除术后胆汁瘤的病例,而未提及在胆囊切除术中或术后发现的胆管损伤的腹腔镜一期修复。主要原因包括辅助技术取得的良好效果;更复杂胆管病变伴随的紧急情况;炎症、积液和解剖结构不清带来的技术挑战;以及医疗事故诉讼的可能性。然而,完善的腹腔镜技术和严格遵守基本手术原则对于避免医源性胆管损伤的发生以及减少其对患者长期残疾的未知影响至关重要。