Department of Surgery, Government Medical College Srinagar, Karan Nagar, Srinagar, 190010, Jammu and Kashmir, India.
World J Surg. 2010 Apr;34(4):784-90. doi: 10.1007/s00268-010-0397-4.
BACKGROUND: Increasingly, laparoscopic biliary surgeons are undertaking laparoscopic cholecystectomy and laparoscopic common bile duct exploration for patients with cholelithiasis and choledocholithiasis. In laparoscopic common bile duct exploration a flexible choledochoscope is ordinarily used, and with this instrument the surgeon usually fails to remove large impacted stones. In contrast with use of a rigid nephroscope it is possible to remove all common bile duct stones irrespective of size and degree of impaction. The present study evaluates the efficiency of rigid nephroscope for managing common bile duct stones laparoscopically. METHODS: In the present study laparoscopic common bile duct exploration for stones was performed in 80 patients via standard laparoscopic cholecystectomy port sites. Patients with a common bile duct diameter >10 mm were included in this study. The rigid nephroscope was passed through the epigastric port and negotiated into the common bile duct through a choledochotomy. Stones were removed with graspers. Large hard stones were fragmented by pneumatic lithotripsy. RESULTS: Of the 80 patients treated in this manner, 72 (90%) had multiple common bile duct calculi, and 8 (10%) had a solitary common bile duct calculus. Mean common bile duct diameter was 15.3 mm (range: 10-37 mm). Conversion to open common bile duct exploration was necessary in 1 case (1.25%) because of difficult dissection secondary to extensive dense adhesions. In 7 patients (8.75%) a pneumatic lithotripter was used to fragment stones. Choledochotomy was managed by placing a T-tube in 21 (26.25%) patients, by effecting primary closure in 58 (72.5%) patients, and by choledochoduodenostomy in 1 (1.25%) patient. The mean operative time in this series was 83 min (range: 53-135 min). The mean postoperative hospital stay was 4.2 days (range: 3-19 days). One patient (1.25%) developed cholangitis 5 months after laparoscopic common bile duct exploration; the cause was a residual common bile duct stone. CONCLUSIONS: A rigid nephroscope can be used for managing all types of common bile duct calculi irrespective of site, size, composition, or degree of impaction. Its use can be expected to become the standard for laparoscopic common bile duct exploration, especially for removing large calculi from a dilated common bile duct.
背景：越来越多的腹腔镜胆道外科医生正在为患有胆石症和胆总管结石的患者进行腹腔镜胆囊切除术和腹腔镜胆总管探查术。在腹腔镜胆总管探查术中，通常使用软式胆道镜，但使用这种器械，外科医生通常无法取出大的嵌顿结石。与使用硬性肾镜相比，可以取出所有大小和嵌顿程度的胆总管结石。本研究评估硬性肾镜在腹腔镜下处理胆总管结石的效率。
方法：本研究中，通过标准腹腔镜胆囊切除术端口对 80 例患者进行腹腔镜胆总管探查术。本研究纳入胆总管直径>10mm的患者。硬性肾镜通过上腹部端口进入，并通过胆总管切开术进入胆总管。结石用抓钳取出。大而硬的结石用气压弹道碎石机破碎。
结果：以这种方式治疗的 80 例患者中，72 例（90%）有多发胆总管结石，8 例（10%）有单发胆总管结石。胆总管平均直径为 15.3mm（范围：10-37mm）。由于广泛致密粘连导致分离困难，1 例（1.25%）患者需要转为开腹胆总管探查术。7 例（8.75%）患者使用气压弹道碎石机碎石。21 例（26.25%）患者通过放置 T 管处理胆总管切开，58 例（72.5%）患者通过胆总管一期缝合处理，1 例（1.25%）患者通过胆总管十二指肠吻合术处理。本系列手术平均时间为 83 分钟（范围：53-135 分钟）。平均术后住院时间为 4.2 天（范围：3-19 天）。1 例（1.25%）患者在腹腔镜胆总管探查术后 5 个月发生胆管炎；原因是残余胆总管结石。
结论：硬性肾镜可用于处理各种类型的胆总管结石，无论结石位置、大小、成分或嵌顿程度如何。预计它的使用将成为腹腔镜胆总管探查术的标准，特别是用于从扩张的胆总管中取出大结石。
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