腹腔镜胆总管囊肿根治术205例并发症分析及经验总结

浙江大学医学院附属儿童医院普外科(浙江省杭州市,310000), E-mail:ebwk@zju.edu.cn

胆总管囊肿; 腹腔镜检查; 手术中并发症; 手术后并发症

Complications of laparoscopic choledochal cyst excision: a report of 205 cases.
Gao Zhigang, Zhang Yaobin, Cai Duote,Chen Qijiang, Xiong Qixing, ZHANG Lifeng.

Department of General Surgery, Affiliated Children's Hospital, Zhejiang University School of Medicine,Hangzhou 310000, China

Choledochal Cyst; Laparoscopy; Intraoperative Complications; Postoperative Complications

DOI: 10.3969/j.issn.1671-6353.2017.01.015

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目的 探讨腹腔镜下胆总管囊肿切除、肝总管空肠Roux-en-Y吻合术围手术期并发症的发生原因及防治对策。 方法 回顾性分析2012年3月至2016年4月本院经腹腔镜行先天性胆总管囊肿根治术的205例患儿临床资料。其中男性35例,女性170例; 囊肿型173例,梭形32例。 结果 204例在腹腔镜下成功完成手术,1例术中因门静脉损伤中转开腹手术止血。全组手术时间2~5.5 h,平均3 h。术中发生右肝管损伤1例,左右肝管分离1例,胆囊动脉变异出血1例,门静脉损伤2例,术中均准确判断并及时处理,无一例发生不良后果。术后出现出血2例,胆漏2例,胆肠吻合口狭窄3例,胰腺炎1例,胆囊窝或膈下包裹性积液2例; 此10例中,再次手术4例,1例为大出血,经再次剖腹探查止血; 3例为胆肠吻合口狭窄再次行腹腔镜下胆肠吻合术。2例胆漏病例中,1例自愈; 1例因腹腔引流不畅行穿刺引流。1例术后胰腺炎,经保守治疗后痊愈。205例患儿均获随访,随访时间3个月至4年,均予肝功能及B超检查,结果显示5例肝内高密度钙化影,2例吻合口狭窄患儿存在肝功能异常,其余病例随访均正常。 结论 腹腔镜下先天性胆总管囊肿切除肝总管空肠Roux-en-Y吻合术是复杂高风险手术,不但需要术前精确评估胆道形态,积极完善术前准备,还需要精细的围手术期监测和及时对症处理; 而娴熟的腹腔镜技术技巧,对减少术中术后并发症的发生起到重要作用。
Objective To explore the perioperative complications of laparoscopic choledochal cyst excision during Roux-en-Y hepatoenterostomy in children. Methods Retrospective analyses were performed for 205 cases of laparoscopic total cyst excision for choledochal cyst during Roux-en-Y hepatoenterostomy from March 2012 to April 2016. There were 35 boys and 170 girls. And the types were cystic(n=173)and fusiform(n=32). Results Laparoscopic procedure was completed successfully for 204 cases. One case of portal vein injury underwent laprotomy for hemostasis. The average operative time was 3(2.5~5.5)hours. Intraoperative complications included right hepatic duct injury(n=1), hepatic duct separation(n=1), bleeding of variation cholecystic artery(n=1)and portal vein injury(n=2). All five cases were handled timely during surgery without adverse consequences. Postoperative complications included hemorrhage(n=2), bile leakage(n=2), anastomotic stenosis(n=3), postoperative pancreatitis(n=1)and gallbladder fossa or subphrenic encapsulated fluid(n=2). Exploratory laparotomy was performed for hemorrhage(n=1)and laparoscopic hepatoenterostomy for anastomosis stenosis(n=3). One case of bile leakage was cured after 3-week peritoneal drainage while another case recovered completely after puncture drainage for encapsulated fluid. During a follow-up period of 3~48 months, 1iver function and ultrasound were re-examined. Five cases of intrahepatic calcification were found. And two cases had abnormal liver function due to anastomotic stenosis. Conclusion s Laparoscopic total cyst excision with Roux-en-Y hepatoenterostomy for choledochal cyst is complex and risky. Accurate preoperative evaluations of bile and cystic ducts, sufficient preoperative preparations, comprehensive perioperative assessments and skillful laparotomic techniques are critical for lowering both intraoperative and postoperative complications.