Centre for Advanced Laparoscopic Surgery, Digestive Disease Centre, Section of Hepatobiliary Surgery, Department of General Surgery, Tan Tock Seng Hospital, Singapore.
Ann Acad Med Singap. 2010 Feb;39(2):136-42.
INTRODUCTION: Laparoscopic common bile duct exploration (CBDE) is becoming more popular in the management of choledocholithiasis due to improved laparoscopic expertise and advancement in endoscopic technology and equipment. This study aimed to evaluate the safety and short-term outcome of laparoscopic CBDE in a single institution over a 3-year period. MATERIALS AND METHODS: A retrospective review of the records of all patients who underwent laparoscopic CBDE in Tan Tock Seng Hospital between January 2006 and September 2008 was conducted. RESULTS: Fifty consecutive patients, with a median age of 60 years (range, 27 to 85) underwent laparoscopic CBDE for choledocholithiasis during the study period. About half of our patients presented as an emergency with acute cholangitis (32.0%) accounting for the majority. A total of 22 (44.0%) patients underwent laparoscopic CBDE as their primary procedure while the remaining 28 (56.0%) were subjected to preoperative ERCP initially. Of the latter group, documented stone clearance was only documented in 5 (17.9%) patients. Laparoscopic CBDE via the transcystic route was performed in 27 (54.0%) patients while another 18 patients (36.0%) had laparoscopic choledochotomy and 1 patient (2.0%) had laparoscopic choledocho-duodenostomy. There were 4 (8.0%) conversions in our series. The median operative time for laparoscopic CBDE via the transcystic route and the laparoscopic choledochotomy were 170 (75-465) and 250 (160-415) minutes, respectively. For the 18 patients who underwent a laparoscopic choledochotomy, T-tube was inserted in 8 (44.4%) patients while an internal biliary stent was placed in 4 (22.2%) with the remaining 6 patients (33.3%) undergoing primary closure of the choledochotomy. The median length of hospital stay was 2 days (range, 1 to 15) with no associated mortality. The main complications (n = 4, 8.0%) included retained CBD stones and biliary leakage. These were treated successfully with postoperative endoscopic retrograde cholangiopancreatography (ERCP) with/without percutaneous drainage with no further surgery required. CONCLUSION: Laparoscopic CBDE is a safe operation with good outcome in managing choledocholithasis. Its dividends include the numerous benefits of minimally invasive surgery. If possible, transcystic extraction is preferred to choledochotomy, as this obviates the need for biliary diversion. ERCP will still hold an important role in certain instances in the management of choledocholithiasis.
简介:由于腹腔镜技术和内镜设备的进步,腹腔镜胆总管探查术(LCBDE)在胆管结石的治疗中越来越受欢迎。本研究旨在评估单中心 3 年内腹腔镜 LCBDE 的安全性和短期疗效。
材料与方法:对 2006 年 1 月至 2008 年 9 月在陈笃生医院行腹腔镜 LCBDE 的所有患者的病历进行回顾性分析。
结果:研究期间,50 例连续患者(中位年龄 60 岁,范围 27-85 岁)因胆管结石行腹腔镜 LCBDE。约一半的患者以急性胆管炎(占 32.0%)为急症就诊。22 例(44.0%)患者行腹腔镜 LCBDE 作为主要手术,其余 28 例(56.0%)患者术前先行 ERCP。在后者中,仅有 5 例(17.9%)患者明确有结石清除。经胆囊管途径行腹腔镜 LCBDE 27 例(54.0%),腹腔镜胆总管切开术 18 例(36.0%),1 例(2.0%)行腹腔镜胆肠吻合术。本研究中有 4 例(8.0%)中转开腹。经胆囊管途径和腹腔镜胆总管切开术的中位手术时间分别为 170(75-465)分钟和 250(160-415)分钟。18 例行腹腔镜胆总管切开术的患者中,8 例(44.4%)留置 T 管,4 例(22.2%)留置胆管内支架,6 例(33.3%)行胆总管切开一期缝合。中位住院时间为 2 天(1-15 天),无相关死亡病例。主要并发症(n=4,8.0%)包括胆总管残余结石和胆漏,均经术后内镜逆行胰胆管造影(ERCP)治疗成功,其中部分患者联合经皮引流,无需进一步手术。
结论:腹腔镜 LCBDE 治疗胆管结石安全有效,具有微创优势。如果可能,经胆囊管途径取石优于胆总管切开术,因为这可以避免胆道引流。在某些情况下,ERCP 在胆管结石的治疗中仍具有重要作用。
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