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    膽囊切除術后殘余膽囊并結石12例分析
    關鍵字:膽囊,分析,CD,EF,GH,AB,yz,uv,wx,IJ, 發布時間:2011-08-20

    膽囊切除術后殘余膽囊并結石12例分析 詹發杰 733000甘肅武威市人民醫院普通外科 摘要目的:探討膽囊切除術后殘余膽 囊并結石的發生原因及診治經驗。方法: 對12例膽囊切除術后殘余膽囊并結石的 臨床資料進行回顧性分析。結果:12例 患者全部手術治愈,無嚴重并發癥。結 論:膽囊切除術后殘余膽囊并結石的發生 是膽囊切除術中多種因素引起的;B超、 ERCP是準確可靠的檢查手段;規范膽囊 切除術操作,膽囊切除手術質量的提高是 可以有效防止或降低其發病率的措施。 本病一旦確診,手術行殘余膽囊切除是首 先的治療。 關鍵詞膽囊切除術殘余膽囊治療 doi:10.3969/j.issn.1007—614x.-2010. 25.036 1998年12月~2008年12月收治膽 囊術后殘余膽囊結石患者12例,現報告 如下。 資料與方法 本組12例,男3例,女9例,年齡25 ~65歲,平均35.6歲。第1次手術情況: 擇期膽囊切除術4例,急診膽囊切除術8 例。手術方式:Lc3例,OC2例,MC7 例。術后1個月一3年內再次出現類似 膽囊炎的癥狀。 膽囊切除手術史后3年內再次出現 類似骨H囊炎癥狀,右上腹痛、后背脹痛11 例,腹痛伴發熱3例,腹痛伴黃疸2例。 右.卜腹深壓痛8例,皮膚鞏膜黃染2例, 體格檢查無陽性體征3例。血常規異常 3例,肝功能異常3例,血尿淀粉酶升高1 例。 B超發現殘留膽囊并結石9例;3例 經MRCP檢查,發現殘留膽囊并結石3 例,2例為B超檢查后陰性病歷;1例經 ERCP檢查發現殘留膽囊并結石1例。 殘留且H-囊伴結石大小不等,單發結石3 例,多發結石9例。 結果 lO例患者行擇期殘余膽囊切除術,2 例患者行殘余膽囊切除術和膽總管探查 “T”形管引流術,無嚴重并發癥發生,全 部治愈出院。 討論 殘余膽囊結石形成的原因:①手術中 將月}{囊管殘端殘留過長且留有結石,手術 中結扎膽囊管時在解剖清晰的情況下,還 要反復觸摸有無膽囊管內粘著的結石,必 要時打JF膽囊管取出膽囊管內結石;②膽 囊切除術中將大膽囊變為小且H囊并存留 結石,近來膽囊大部切除術式已很少采 用,且H囊大部切除只能在特殊情況下采 用,應嚴格掌握適應證并慎用一。;③且fI囊 切除術式選擇不合適;④術者經驗不足, 未按規范性手術操作,使月嗵囊管殘株過 長。 膽囊術后殘余膽囊并結石的診斷多 有誤診和漏診,在術后開始發作時常常冠 以膽囊術后綜合征,隨著發作次數的增 加,癥狀的明顯,殘余膽囊腔的擴大以及 結石的增大,影像檢查多能明確診斷。既 往且H囊手術史,再次出現類似膽囊炎癥 狀,B超、MRCP、ERCPR陽性發現是確診 的手段。 本病一日.確診,首選手術治療,在 全麻下行擇期殘余膽囊切除術。再手 術時麻醉要完善,完善的麻醉彳‘有手術 良好的濕露。本研究中有3例與上次 膽囊手術中麻醉不完善,術野顯露不 好,未能清楚地顯露膽囊=三角的因素。 再次手術具有一定的難度、復雜性,應 組織經驗豐富的手術小組,一般選原切 口并適當延長。手術關鍵是找到殘余 膽囊,在肝床下由淺入深由左向右仔細 解剖,最好是在分離過程中能觸摸到殘 余結石,其次通過穿刺抽得膽汁,再次 可通過解剖出肝管后逆行找到殘余膽 囊。必要時行術中膽道造影等以明確 解剖關系。為防止意外的副損傷在分 離找到殘余膽囊后最好打開殘余膽囊, 取出結石后,在膽囊殘腔內引導下分離 膽囊管,對于有部分結石粘著于鵬囊管 的要剖開膽囊管取出結石,以防止結石 的再次殘留,距月H總管0.5Cln結扎膽 囊管,切除殘余膽囊并結石。 防止殘余膽囊的發生,必須強調膽囊 切除術操作規范,提高膽囊切除術的質 量,術者應注意:①必須高度重視,應按膽 囊切除術常規步驟精心細致地操作,耐心 地解剖,必須追朔到膽囊管匯人肝(膽) 總管處,明辨“三管”關系后妥善處理膽 囊管;②應警惕膽囊管有無結石殘留,以 手指觸摸行將結扎的膽囊管,可將結石推 擠至結扎的膽囊側,否則,應切開、取出結 石后再結扎;③LC操作者必須有開腹膽 囊切除術的豐富經驗,必須做到訓練有 素;④丑H囊切除術要根鉛病人的情況,醫 生的經驗選擇合適的術式。 引起殘余膽囊的諸多因素中,術者的 因素起著決定性作用,提高術者的素質是 預防殘余且H囊的父鍵:①術者應提高對膽 囊切除術和殘余膽囊的認識,行小切口膽 囊切除術或Lc時,在追求低損傷的同時 注意防止殘余膽囊的發生;②術者熟練掌 握膽道的局部解剖和膽囊三角的解削方 法,耐心、仔細并嚴格按照操作規程進行, 不要為了刻意追求手術速度而草率行事; ③反對輕率實施肌囊大部切除術,謹慎對 待小切u膽囊切除術,嚴格掌握膽囊大部 切除術的適應證;④在施行膽囊部分切除 術時應強調對殘余膽囊黏膜的處理,可以 采取刮除、碘酒或酒精燒灼的方法,祛除 其分泌功能,殘腔大者要用帶蒂大網膜填 塞縫合固定,防止小膽囊的生成、殘株再 發以及結石的形成;⑤避免膽囊管殘留結 石,切除且H囊時應充分顯露膽囊‘角,仔 細捫診膽囊管傘程,必要時切開膽囊管取 石,或經檢查r解膽系解削及有無結石殘 留;同時,術中做膽道鏡檢查,可有效避免 殘留結石。 參考文獻 1付由,池高,志清.殘余膽囊36例病因分析 與診治.人民軍醫,2001。44(3). 2WalshRM,ponsky幾,doumotj.Retainedsan? baddeer/cystieductremnantcalculia8 acause ofpostcholecystectomypain[J].Surgendosc, 2002,16:981—984. 3夏穗生,黃莛庭,石景森,等.膽囊大部切除 術的適應證和技術要求.中華肝膽外科雜 志,2001,7:307—309. 4任猶駿,徐炳文,熊艷.殘余月H囊的處理和 預防.肝膽外科雜志,2006.14(1):58—75. 5石景森.努力提高膽囊殘留病變的防治水 平.中華肝膽外科雜志。2002。8:451—452. 中國社區醫師?醫學專業2010年第25期(第12卷總第250期)41 萬方數據 換頁

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