Gouma D J, Go P M
Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
J Am Coll Surg. 1994 Mar;178(3):229-33.
It has been suggested that the risk of injury to the bile duct is higher after laparoscopic cholecystectomy than after conventional cholecystectomy. The results of previous studies on laparoscopic cholecystectomy showed no difference but they were limited (positive) selections from highly specialized centers. Thus, a questionnaire was sent to all surgical departments in The Netherlands to analyze the number of repair procedures for bile duct injury, the techniques and complications of this treatment and the number of cholecystectomies performed during 1991 to determine the "actual" risk of bile duct injury. The response was 88.4 percent (122 of 138 centers). A total of 11,712 cholecystectomies were performed, of which 2,932 were laparoscopic and 8,780 were conventional. Thirty-two bile duct injuries resulted from laparoscopic cholecystectomy (1.09 percent) and 45 resulted from conventional cholecystectomy (0.51 percent) (p < 0.001). Thirty-six injuries (46.7 percent) were detected during the procedure or within 24 hours and 41 (53.2 percent) after a mean period of ten days. The bile duct lesion consisted of transection in 35 patients (45.5 percent), a stenosis or clips in 17 patients (22.1 percent) and a lesion with bile leakage in 25 patients (32.5 percent). The repair procedure included primary closure or end to end anastomosis in 33 patients (42.8 percent) and hepatojejunostomy in 31 patients (40.2 percent). Hepatojejunostomy was performed upon 17 percent of the injuries detected early and in 61 percent of the injuries detected after a delay. Complications were found in 31.1 percent and the mortality rate was 7.8 percent. In summary, the risk of bile duct injury after laparoscopic cholecystectomy was significantly (p < 0.001) higher than after conventional cholecystectomy, which was probably related to the relative inexperience (all units from one country). The risk of bile duct injury after conventional cholecystectomy was slightly higher than that found in literature, which probably reflects the fact that we studied the number of "repair procedures" instead of registration of complications (injury). Repair procedures for lesion detected after a delay are more complicated (hepatojejunostomy) than for the injury detected early.
有人认为，腹腔镜胆囊切除术后胆管损伤的风险高于传统胆囊切除术后。以往关于腹腔镜胆囊切除术的研究结果显示并无差异，但这些研究是从高度专业化中心进行的（阳性）选择。因此，向荷兰所有外科科室发送了一份调查问卷，以分析胆管损伤修复手术的数量、该治疗方法的技术及并发症，以及1991年期间进行的胆囊切除术数量，从而确定胆管损伤的“实际”风险。回复率为88.4%（138个中心中的122个）。共进行了11,712例胆囊切除术，其中2,932例为腹腔镜手术，8,780例为传统手术。腹腔镜胆囊切除术导致32例胆管损伤（1.09%），传统胆囊切除术导致45例胆管损伤（0.51%）（p<0.001）。36例损伤（46.7%）在手术过程中或术后24小时内被发现，41例（53.2%）在平均十天后被发现。胆管病变包括35例患者的横断伤（45.5%）、17例患者的狭窄或夹子夹闭（22.1%）以及25例患者的胆汁漏出病变（32.5%）。修复手术包括33例患者的一期缝合或端端吻合（42.8%）以及31例患者的肝空肠吻合术（40.2%）。在早期发现的损伤中，17%进行了肝空肠吻合术，而在延迟发现的损伤中，61%进行了肝空肠吻合术。发现31.1%有并发症，死亡率为7.8%。总之，腹腔镜胆囊切除术后胆管损伤的风险显著高于传统胆囊切除术（p<0.001），这可能与相对缺乏经验有关（所有单位来自一个国家）。传统胆囊切除术后胆管损伤的风险略高于文献报道，这可能反映了我们研究的是“修复手术”数量而非并发症（损伤）登记这一事实。延迟发现的病变的修复手术（肝空肠吻合术）比早期发现的损伤更为复杂。
