Petelin J B
Department of Surgery, University of Kansas School of Medicine, Kansas City, KS 66104, USA.
Surg Endosc. 2003 Nov;17(11):1705-15. doi: 10.1007/s00464-002-8917-4. Epub 2003 Sep 10.
Herein I describe my >12-year experience with laparoscopic common bile duct exploration (LCBDE).
From 21 September 1989 through 31 December 2001, 3,580 patients presented with symptomatic biliary tract disease. Laparoscopic cholecystecomy (LC) was attempted in 3,544 of them (99.1%) and completed in 3,527 (99.5%). Laparoscopic cholangiograms (IOC) were performed in 3,417 patients (96.4%); in 344 cases (9.7%), the IOC was abnormal. Forty-nine patients (1.4%) underwent preoperative endoscopic retrograde cholangiopancreatography (ERCP), and 33 patients (0.9%) underwent postoperative ERCP. LCBDE was attempted in 326 cases and completed in 321 (98.5%). It was successful in clearing the duct in 317 of the 344 patients with abnormal cholangiograms (92.2%).
The mean operating time for all patients undergoing LC with or without cholangiograms or LCBDE or other additional surgery was 56.9 min. Mean length of stay was 22.1 h. The mean operating time for LC only patients ( n = 2530)--that is, those not undergoing LCBDE or any other additional procedure--was 47.6 min; their mean postoperative length of stay was 17.2 h. Ductal exploration was performed via the cystic duct in 269 patients, (82.5%) and through a choledochotomy in 57 patients (17.5%). T-tubes were used in patients in whom there was concern for possible retained debris or stones, distal spasm, pancreatitis, or general poor tissue quality secondary to malnutrition or infection. In cases where choledochotomy was used, a T-tube was placed in 38 patients (67%), and primary closure without a T-tube was done in 19 (33%). There were no complications in the group of patients who underwent choledochotomy and primary ductal closure without T-tube placement or in the group in whom T-tubes were placed.
Common bile duct (CBD) stones still occur in 10% of patients. These stones are identified by IOC. IOC can be performed in >96.4% of cases of LC. LCBDE was successful in clearing these stones in 97.2% of patients in whom it was attempted and in 92.2% of all patients with normal IOCs. Most LCBDEs in this series were performed via the cystic duct because of the stone characteristics and ductal anatomy. Selective laparoscopic placement of T-tubes in patients requiring choledochotomy (67%) appears to be a safe and effective alternative to routine T-tube drainage of the ductal system. ERCP, which was required for 5.8% of patients with abnormal cholangiograms, and open CBDE, which was used in 2.0%, still play an important role in the management of common bile duct pathology. The role of ERCP, with or without sphincterotomy, has returned to its status in the prelaparoscopic era. LCBDE may be employed successfully in the vast majority of patients harboring CBD stones.
在此，我描述我超过12年的腹腔镜胆总管探查术（LCBDE）经验。
从1989年9月21日至2001年12月31日，3580例患者出现有症状的胆道疾病。其中3544例（99.1%）尝试进行腹腔镜胆囊切除术（LC），3527例（99.5%）完成该手术。3417例患者（96.4%）进行了术中胆管造影（IOC）；344例（9.7%）的IOC结果异常。49例患者（1.4%）接受了术前内镜逆行胰胆管造影（ERCP），33例患者（0.9%）接受了术后ERCP。326例尝试进行LCBDE，321例（98.5%）完成该手术。在344例胆管造影异常的患者中，317例（92.2%）成功清除了胆管结石。
所有接受LC（无论是否进行胆管造影、LCBDE或其他附加手术）的患者平均手术时间为56.9分钟。平均住院时间为22.1小时。仅接受LC的患者（n = 2530），即未进行LCBDE或任何其他附加手术的患者，平均手术时间为47.6分钟；他们的平均术后住院时间为17.2小时。269例患者（82.5%）通过胆囊管进行胆管探查，57例患者（17.5%）通过胆总管切开术进行探查。对于担心可能有残留碎片或结石、远端痉挛、胰腺炎或因营养不良或感染导致组织质量普遍较差的患者，使用了T管。在采用胆总管切开术的病例中，38例患者（67%）放置了T管，19例（33%）进行了无T管的一期缝合。在进行胆总管切开术和无T管放置的一期胆管缝合的患者组或放置T管的患者组中均未出现并发症。
胆总管（CBD）结石在10%的患者中仍然存在。这些结石通过IOC得以识别。IOC可在超过96.4%的LC病例中进行。LCBDE在97.2%尝试该手术的患者以及92.2%所有IOC结果正常的患者中成功清除了这些结石。由于结石特征和胆管解剖结构，本系列中的大多数LCBDE通过胆囊管进行。对于需要胆总管切开术的患者，选择性腹腔镜放置T管（67%）似乎是胆管系统常规T管引流的一种安全有效的替代方法。5.8%胆管造影异常的患者需要ERCP，2.0%的患者采用了开放性CBD手术，它们在胆总管病变的管理中仍然发挥着重要作用。无论是否进行括约肌切开术，ERCP的作用已恢复到腹腔镜时代之前的状态。LCBDE可成功应用于绝大多数患有CBD结石的患者。
