Martin I J, Bailey I S, Rhodes M, O'Rourke N, Nathanson L, Fielding G
Royal Brisbane and Wesley Hospitals, Queensland, Australia.
Ann Surg. 1998 Jul;228(1):29-34. doi: 10.1097/00000658-199807000-00005.
OBJECTIVE: To establish a simple, reproducible, and safe technique of laparoscopic common bile duct exploration (CBDE) with high clearance rates and low morbidity and mortality rates. SUMMARY BACKGROUND DATA: For most general surgeons, laparoscopic CBDE appears an unduly complex and demanding procedure. Since the introduction of laparoscopic cholecystectomy, many surgeons use endoscopic cholangiography (ERC) and endoscopic sphincterotomy as their only option in treating bile duct stones. ERC is more specific if used after surgery, but it carries an appreciable morbidity rate and has the disadvantage of requiring a second procedure to deal with bile duct stones. To this end, various methods of laparoscopic CBDE have been developed. METHODS: Between August 1991 and February 1997, 300 consecutive unselected patients underwent laparoscopic CBDE. RESULTS: Of 300 laparoscopic CBDE procedures, 173 (58%) were managed using a transcystic approach and 127 (42%) with choledochotomy. Successful laparoscopic stone clearance was achieved in 271 (90%). Of the 29 (10%) patients not cleared laparoscopically, 10 had an elective postsurgical ERC, 12 were converted to an open procedure early in the series, and 7 had unexpected retained stones. There was one death (mortality rate 0.3%) and major morbidity occurred in 22 patients (7%). The last 100 procedures were performed from July 1995 to February 1997, and stone clearance was unsuccessful in only two patients. CONCLUSIONS: Laparoscopic transcystic basket extraction of common duct stones under fluoroscopic guidance is a relatively quick, successful, and safe technique. Choledochotomy, when required, is associated with a higher morbidity rate, particularly with T-tube insertion, and the authors advocate primary bile duct closure with or without insertion of a biliary stent as a more satisfactory technique for both surgeon and patient. Most patients with gallbladder and common duct calculi should expect a curative one-stage laparoscopic procedure without the need for external biliary drainage or ERC.
目的：建立一种简单、可重复且安全的腹腔镜胆总管探查术（CBDE）技术，该技术具有高结石清除率以及低发病率和死亡率。 总结背景资料：对于大多数普通外科医生而言，腹腔镜CBDE似乎是一个过于复杂且要求较高的手术。自腹腔镜胆囊切除术引入以来，许多外科医生将内镜胆管造影术（ERC）和内镜括约肌切开术作为治疗胆管结石的唯一选择。术后使用ERC更具特异性，但它具有相当高的发病率，并且存在需要二次手术来处理胆管结石的缺点。为此，已开发出各种腹腔镜CBDE方法。 方法：在1991年8月至1997年2月期间，300例未经挑选的连续患者接受了腹腔镜CBDE。 结果：在300例腹腔镜CBDE手术中，173例（58%）采用经胆囊途径处理，127例（42%）采用胆总管切开术。271例（90%）成功实现了腹腔镜下结石清除。在29例（10%）未通过腹腔镜清除结石的患者中，10例接受了择期术后ERC，12例在该系列手术早期转为开放手术，7例有意外残留结石。有1例死亡（死亡率0.3%），22例患者（7%）发生了严重并发症。最后100例手术于1995年7月至1997年2月进行，仅2例结石清除未成功。 结论：在荧光镜引导下经胆囊篮式取出胆总管结石是一种相对快速、成功且安全的技术。必要时进行胆总管切开术的发病率较高，尤其是放置T管时。作者主张对于外科医生和患者而言，无论是否放置胆道支架，一期缝合胆总管是一种更令人满意的技术。大多数患有胆囊和胆总管结石的患者应期望通过一期腹腔镜手术治愈，而无需进行外引流或ERC。
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