程序化改良腹腔镜经胆囊管胆总管探查取石术的应用策略

Application strategy of programmatic improvement in laparoscopic transcystic common bile duct exploration

摘要:

背景与目的 腹腔镜经胆囊管胆总管探查取石术（LTCBDE）以创伤小、恢复快、并发症发生少等优势，已逐渐成为治疗继发性胆总管结石的首选方法。然而，术中胆囊管扩张、胆道镜置入、肝总管及肝内胆管探查仍是技术难点。本研究探讨程序化改良LTCBDE在治疗胆囊结石合并胆总管结石中的临床应用及其效果。方法 回顾性分析2018年1月—2024年1月期间，苏州大学附属苏州九院248例接受程序化改良LTCBDE患者的临床资料，总结其手术策略与治疗效果。同时，收集同期913例行腹腔镜胆总管切开探查取石术（LCBDE）的患者数据，比较两组患者的手术效果与术后并发症。结果 通过程序化手术步骤、创新“隔膜”切开技术及胆道探条的改良应用，共244例（98.4%）患者成功完成LTCBDE，4例因无法将4.9 mm胆道镜经胆囊管插入胆总管转为LCBDE。术后，1例（0.4%）发现胆道结石残留，后经T管窦道取石成功（该例术中转为LCBDE）；另有1例胆汁漏及1例腹腔感染（各0.4%），经保守治疗恢复。术后未见腹腔出血、胆道狭窄或胆道损伤等其他并发症。程序化改良LTCBDE组的平均手术时间与LCBDE组相当（85.2 min vs. 88.0 min，P=0.398），但术后住院时间明显短于LCBDE组（6.2 d vs. 8.3 d，P<0.001），且并发症发生率更低（1.6% vs. 4.7%，P=0.044）。结论 程序化改良LTCBDE步骤规范、操作安全且疗效显著，具有较低的并发症发生率，值得在临床中进一步推广应用。

Abstract:

Background and Aims Laparoscopic transcystic bile duct exploration (LTCBDE) has become the preferred method for treating secondary bile duct stones due to its advantages of minimal trauma, fast recovery, and low complication rates. However, challenges remain in the dilation of the cystic duct, the insertion of the choledochoscope, and the exploration of the common hepatic duct and intrahepatic bile ducts. This study was performed to explore the clinical application and effectiveness of the programmed modified LTCBDE in the treatment of gallbladder stones combined with common bile duct stones.Methods A retrospective analysis was conducted on the clinical data of 248 patients who underwent programmed modified LTCBDE at the Affiliated Suzhou Ninth Hospital of Soochow University from January 2018 to January 2024. The surgical strategies and treatment outcomes were summarized. Data from 913 patients who underwent laparoscopic common bile duct exploration (LCBDE) during the same period were also collected to compare surgical outcomes and postoperative complications between the two groups.Results Through programmed surgical steps, the innovative "diaphragm" incision technique, and improved bile duct probe application, 244 patients (98.4%) successfully underwent LTCBDE, while 4 patients were converted to LCBDE due to failure to insert a 4.9 mm choledochoscope through the cystic duct. After operation, 1 patient (0.4%) had residual bile duct stones, which were successfully removed through T-tube tract stone extraction (this patient was converted to LCBDE during the procedure). Additionally, 1 case of bile leakage and 1 case of abdominal infection (each 0.4%) occurred, both of which resolved with conservative treatment. No cases of intra-abdominal bleeding, bile duct stenosis, or bile duct injury were reported. The average operative time in the programmed modified LTCBDE group was comparable to that of the LCBDE group (85.2 min vs. 88.0 min, P=0.398), but the postoperative hospital stay was significantly shorter (6.2 d vs. 8.3 d, P<0.001), and the incidence of complications was lower (1.6% vs. 4.7%, P=0.044).Conclusion The programmed modified LTCBDE is a standardized, safe, and effective procedure with a low complication rate. It is worthy of further clinical promotion and application.