Windsor J A, Pong J
Surgical Skills Training Centre, Department of Surgery, Faculty of Medicine and Health Science, University of Auckland, New Zealand.
Aust N Z J Surg. 1998 Mar;68(3):186-9. doi: 10.1111/j.1445-2197.1998.tb04742.x.
The increase in the incidence of iatrogenic injury to the extrahepatic biliary tree that has been documented since the introduction of laparoscopic cholecystectomy (LC) has been explained as a 'learning curve' problem. The early New Zealand experience has been published and the present study was undertaken to determine whether there had been any change in the incidence, nature and management of laparoscopic biliary injuries (LBI) after further experience with LC.
A nationwide audit was undertaken in 1995 by two confidential postal questionnaires: to all active general surgeons (n=184, response rate 60%), and to all endoscopists performing endoscopic retrograde cholangiopancreatography (ERCP) (n=18, response rate 100%).
The total number of LBI was 21, compared with 41 for 1991-92. The site and nature of the injuries were similar for the two survey periods. More of the injuries appeared to be diagnosed after the operation and prior to discharge (25% vs 47%). Calculating the national incidence of LBI was not possible without complete reporting, but in the subset of surgeons responsible for the LBI there was no apparent decrease in the incidence of all LBI (2.8% vs 2.9%), those requiring active re-intervention (2.4% vs 2.7%) and major duct injury (1.1% vs 0.7%), despite a significant increase in the surgeons' prior experience with LC (20% vs 61% of surgeons had performed more than 100 LC). There were some concerning trends in management: a less frequent use of ERCP in patients with LBI diagnosed after surgery (76% vs 65%) and a higher proportion of patients with minor injuries managed by re-operation (26% vs 50%).
The present study indicates that iatrogenic biliary injury is a persistent problem in New Zealand, despite increasing experience with LC, and suggests the need for more intensive scrutiny of operative technique and training. There is scope to manage more patients with minor duct injuries conservatively.
自腹腔镜胆囊切除术（LC）开展以来，肝外胆管医源性损伤的发生率有所增加，这一现象被解释为“学习曲线”问题。新西兰早期的经验已经发表，本研究旨在确定在积累了更多LC经验后，腹腔镜胆管损伤（LBI）的发生率、性质及处理方式是否发生了变化。
1995年通过两份保密邮政问卷在全国范围内进行了调查：一份发给所有在职普通外科医生（n = 184，回复率60%），另一份发给所有进行内镜逆行胰胆管造影（ERCP）的内镜医师（n = 18，回复率100%）。
LBI总数为21例，而1991 - 1992年为41例。两个调查时期损伤的部位和性质相似。更多的损伤似乎是在术后出院前被诊断出来的（25%对47%）。如果没有完整的报告，就无法计算全国LBI的发生率，但在负责LBI的外科医生子集中，所有LBI（2.8%对2.9%）、需要积极再次干预的LBI（2.4%对2.7%）和主要胆管损伤（1.1%对0.7%）的发生率并没有明显下降，尽管外科医生之前进行LC的经验显著增加（进行过100例以上LC的外科医生比例从20%升至61%）。在处理方式上存在一些令人担忧的趋势：术后诊断为LBI的患者中ERCP的使用频率降低（76%对65%），以及通过再次手术处理的轻伤患者比例更高（26%对50%）。
本研究表明，尽管LC经验不断增加，但医源性胆管损伤在新西兰仍然是一个持续存在的问题，并提示需要对手术技术和培训进行更严格的审查。对于轻度胆管损伤的患者，有保守治疗的空间。
