Dion Y M, Ratelle R, Morin J, Gravel D
Department of Surgery, St-François d'Assie Hospital, Laval University, Québec City, Canada.
Surg Laparosc Endosc. 1994 Dec;4(6):419-24.
Since laparoscopic cholecystectomy was introduced, the treatment of choledocholithiasis has been modified. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) has been performed selectively in elderly patients and in those with a strong suspicion of biliary duct stones (jaundice, demonstrated at ultrasound). Intraoperative discovery of common duct stones at cystic duct cholangiography signifies that they must be removed intraoperatively [or postoperatively by ERPC and endoscopic sphincterotomy (ES)]. As ES has a failure rate of 3-23%, laparoscopic common duct exploration emerges as the treatment of choice. Since November 1990, we have performed 59 laparoscopic common bile duct explorations. In our experience, the transcystic technique (18 patients) with choledochoscopy appears easier to perform than with fluoroscopy without choledochoscopy. Since, during our early experience, we encountered some difficulty with the transcystic technique, we elected to evaluate common duct exploration through a choledochotomy (41 patients). The main advantage of this technique is that it provides complete access to the ductal system without damage to the papilla. This procedure seems more difficult to perform than the transcystic technique and can be used when there are contraindications to the latter.
自从腹腔镜胆囊切除术问世以来，胆总管结石的治疗方法已有所改变。术前内镜逆行胰胆管造影（ERCP）已选择性地应用于老年患者以及那些高度怀疑有胆管结石（超声显示有黄疸）的患者。术中在胆囊管胆管造影时发现胆总管结石意味着必须在术中取出（或术后通过ERPC及内镜括约肌切开术（ES）取出）。由于ES的失败率为3% - 23%，腹腔镜胆总管探查术成为首选的治疗方法。自1990年11月以来，我们已进行了59例腹腔镜胆总管探查术。根据我们的经验，采用经胆囊管技术（18例患者）并结合胆管镜检查似乎比不使用胆管镜检查的荧光透视法更容易操作。由于在我们早期的经验中，经胆囊管技术遇到了一些困难，我们选择通过胆总管切开术评估胆总管探查（41例患者）。该技术的主要优点是可以完全进入胆管系统而不损伤乳头。此手术似乎比经胆囊管技术更难实施，并且当经胆囊管技术存在禁忌证时可以采用。
