Doganay M, Kama N A, Reis E, Kologlu M, Atli M, Gozalan U
Fourth Department of Surgery, Ankara Numune Hospital, Ankara, Turkey.
Surg Endosc. 2002 Jan;16(1):216. doi: 10.1007/s004640042026. Epub 2001 Nov 12.
The introduction of laparoscopic cholecystectomy in surgical practice resulted with an increased incidence of bile duct injuries and required new classification systems. This article presents six cases of major bile duct injuries that occurred in our first 1,000 laparoscopic cholecystectomies. Four female and two male patients (ages, 36-71 years) were detected to have major bile duct injuries. Laparoscopic dissection was difficult because of acute inflammation in four patients and fibrosis in two patients. These six cases were between laparoscopic cholecystectomies 26 and 377 performed by the operating surgeons. Three of the patients had type E2 injury according to the Strasberg classification: one detected intraoperatively and the other two postoperatively. All were treated with Roux-en-Y hepaticojejunostomy. The other three patients had type D injuries: two realized intraoperatively and one postoperatively. Two of these injuries were repaired primarily over a T-tube. The remaining patient, whose injury was realized intraoperatively, underwent nasobiliary drainage postoperatively. Only one patient had a complication associated with a trocar injury to the liver parenchima during the first operation. A hepatic abscess and external biliary fistula developed, which were treated conservatively. At this writing, all the patients are well and without problems after 2.5 to 6 years of follow-up evaluation. Difficulties in laparoscopic dissection because of severe inflammation or fibrosis resulted in injuries to our patients. We can underscore the fact that experience may not always protect from complications, and that conversion to laparotomy might have prevented some of these injuries. Patients with a minor injury and a controlled leak can be treated by a combination of surgical and endoscopic or radiologic techniques. The treatment plan must be individualized for every patient, depending on the injury type, presentation, and condition of the patient.
腹腔镜胆囊切除术应用于外科实践后，胆管损伤的发生率有所增加，因此需要新的分类系统。本文介绍了在我们最初的1000例腹腔镜胆囊切除术中发生的6例主要胆管损伤病例。4例女性和2例男性患者（年龄36 - 71岁）被检测出有主要胆管损伤。由于4例患者存在急性炎症、2例患者存在纤维化，腹腔镜解剖操作困难。这6例病例发生在手术医生进行的第26至377例腹腔镜胆囊切除术之间。根据Strasberg分类，其中3例患者为E2型损伤：1例术中发现，另外2例术后发现。所有患者均接受了Roux - en - Y肝空肠吻合术治疗。另外3例患者为D型损伤：2例术中发现，1例术后发现。其中2例损伤在T形管支撑下进行了一期修复。剩下的1例术中发现损伤的患者术后进行了鼻胆管引流。仅1例患者在首次手术期间出现与套管针损伤肝实质相关的并发症，并发肝脓肿和外胆管瘘，经保守治疗。撰写本文时，所有患者在2.5至6年的随访评估后情况良好，无问题。严重炎症或纤维化导致的腹腔镜解剖困难致使我们的患者受到损伤。我们可以强调这样一个事实，经验未必总能预防并发症，而转为开腹手术可能会避免其中一些损伤。轻度损伤且漏液可控的患者可通过手术与内镜或放射技术联合治疗。治疗方案必须根据每位患者的损伤类型、表现和病情进行个体化制定。
