Richardson M C, Bell G, Fullarton G M
Department of Surgery, Gartnavel General Hospital, Glasgow, UK.
Br J Surg. 1996 Oct;83(10):1356-60. doi: 10.1002/bjs.1800831009.
The rapid introduction of laparoscopic cholecystectomy has been associated with an apparently increased incidence of bile duct injury which has provoked worldwide concern. The true incidence and mechanism of iatrogenic ductal injury during the development of this procedure remain unclear. To assess this, the introduction of laparoscopic cholecystectomy in the West of Scotland has been audited prospectively over a 5-year period. All cases of biliary ductal injury have been independently reviewed. Some 48 surgeons undertaking laparoscopic cholecystectomy in 19 hospitals submitted prospective data between September 1990 and September 1995. A total of 5913 laparoscopic cholecystectomies were attempted with 98.3 per cent completion of data collection. During this period 37 laparoscopic bile duct injuries occurred. The annual incidence peaked at 0.8 per cent and has fallen to 0.4 per cent in the final year of audit. Injuries occurred after a median personal experience of 51 (range 3-247) laparoscopic cholecystectomies in 22 surgeons. Major bile duct injuries occurred in 20 of 37 patients, giving an incidence of 0.3 per cent. Five mechanisms for laparoscopic ductal injury were identified, including tenting, confluence and diathermy injuries as well as the classical and variant classical types. Ductal injuries were discovered at operation in 18 patients with consequent repair giving a good clinical outcome in 17. Contributory factors (severe inflammation, aberrant anatomy and poor visualization) were present in only 13 of 37 cases. This audit suggests that, at least in the introductory period, laparoscopic cholecystectomy is associated with an overall bile duct injury rate higher than that reported previously after open cholecystectomy, although the incidence of major ductal injury is similar. The late downward trend in bile duct injury, however, suggests there may be a prolonged learning curve for this procedure. Improved understanding of the mechanism of injury may lead to yet further reductions in this complication.
腹腔镜胆囊切除术的迅速推广与胆管损伤发生率明显增加相关，这已引起全球关注。在此手术发展过程中，医源性胆管损伤的真实发生率及机制仍不清楚。为评估这一点，对苏格兰西部5年内前瞻性引入腹腔镜胆囊切除术的情况进行了审核。所有胆管损伤病例均进行了独立评估。1990年9月至1995年9月期间，19家医院的约48名外科医生进行了腹腔镜胆囊切除术并提交了前瞻性数据。共尝试进行5913例腹腔镜胆囊切除术，数据收集完成率为98.3%。在此期间发生了37例腹腔镜胆管损伤。年发生率最高达到0.8%，在审核的最后一年降至0.4%。22名外科医生在个人平均经历了51例（范围3 - 247例）腹腔镜胆囊切除术后发生了损伤。37例患者中有20例发生了主要胆管损伤，发生率为0.3%。确定了腹腔镜胆管损伤的五种机制，包括牵拉、汇合处和电灼损伤以及经典型和变异经典型。18例患者在手术中发现了胆管损伤并进行了修复，17例临床结果良好。37例病例中只有13例存在促成因素（严重炎症、解剖结构异常和视野不佳）。此次审核表明，至少在引入阶段，腹腔镜胆囊切除术总体胆管损伤率高于此前开腹胆囊切除术后报告的损伤率，尽管主要胆管损伤发生率相似。然而，胆管损伤的后期下降趋势表明该手术可能存在较长的学习曲线。对损伤机制的更好理解可能会进一步降低这种并发症的发生率。
