腹腔镜胆囊切除术，胆总管结石探查

Detection and Management of CBD Stones within the Era of Laparoscopic Cholecystectomy

                               
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Laparoscopic Cholecystectomy was initially conducted by Prof Dr Med Erich Muhe of Boblingen, Germany, on 12th September, 1985. This individual was reprimanded by the German surgical Community for carrying this out procedure. Later in 1992, he received the highest honor in the same society-The German Surgical Society Anniversary Award. Dr. Philip Mouret, of Lyon France, performed laparoscopic cholecystectomy in 1987. Dr Reddick as well as Dr Olsen of Nashville, Tennessee USA, performed laparoscopic cholecystectomy in 1989 . Since that time, laparoscopic cholecystectomy has rapidly become the recognized treating choice for patients having symptomatic gallbladder disease.

However, although the surgeons have been fascinated by the particular non-invasive process of Laparoscopic Cholecystectomy, their main hurdle had been CBD stones. It's been estimated which about 10% of all patients along with gall stone disease also provide CBD stones. So, the surgeons had to take into account the method to diagnose CBD stones - pre, intra and post operatively and the way to deal with them in a minimally invasive method.

In 1991, Spaw, Reddick and Olsen released the first description of Laparoscopic-guided Cholangiography. Even so, though officially feasible, this process had been usually hard to conduct with the instruments offered at that point. Therefore surgeons relied heavily on preoperative methods of detecting CBD stones for example ERCP (endoscopic retrograde cholangio-pancreatography). When the CBD stones were found pre- operatively, then the surgeons strongly advised patients to endure endoscopic sphincteroscopy with stone extraction before embarking
on laparoscopic cholecystectomy.

Thus the era of Laparoscopic Cholecystectomy began more than two decades ago. In those times the diagnosis and management of CBD stones has evolved.

The diagnosis and management of CBD stones can be made:

a. Pre-operative
b. Intra-operative
c. Post-operative

Pre-operative Diagnosis as well as Management Of CBD Stones

Clinical Presentation

Majority of patients along with persistent popular bile duct stones can be easily identified just before surgical intervention.

• Many patients supply history of problems of upper abdominal pain, starting within the epigastrium or right hypochondrium and radiating towards the back or shoulder.
• Patients sometimes give good reputation for transient jaundice or passing of dark coloured urine.
• History of fever with chills also could accompany this.
• Patients may also present along with cholangitis or acute pancreatitis.

Biochemical Tests
• Elevated serum bilirubin-direct a lot more than indirect
• Elevated alkaline phosphatase
• Elevated transaminase levels
• Elevated amylase or lipase levels

Radiological Tests

1. Plain x-ray of stomach may display radio-opaque shadow in the correct hypochondrium.
2. Ultrasound of belly will display one or two stones within the budget of the common bile duct. Sometimes, the low end of the common bile duct may be obscured by gas within the duodenum and hence the stones might not be observed clearly. In that case the ultrasound will certainly display dilated proximal bile duct and occasionally additionally intra-hepatic biliary dilatation.
3. MRCP (Magnetic Resonance Cholangio Pancreatography) - This is a non invasive procedure and gives an excellent anatomical picture of liver, gall bladder and whole biliary tree. Thus it is specifically useful to see stones in the lower end of typical bile duct.
4. CT scan - This is useful when one wants to rule out any other lesion which can be suspected since the cause of obstructive jaundice.

Endoscopic Tests

1. Endo Sonography - It becomes an invasive process, though less invasive than ERCP. A part viewing flexible endoscope which has sonography incorporated, is an excellent tool to diagnose stones in the lower end of typical bile duct.
2. ERC (Endoscopic Retrograde Cholangiography)- This is an invasive procedure and will deliniate the anatomy and also character of obstruction from the biliary tree. Apart from, it's the benefit of carrying on to therapeutic management to deal with the obstruction, based on its nature.

Treatment

1. Once the common bile stones are detected, ERCP, sphincterotomy and stone extraction may be the treatment of choice. If the stones are cleared completely, than the is followed by laparoscopic cholecystectomy.
2. If the common bile duct stones are not cleared completely or if the stones are bigger than 2.5 cm, then your surgeon might want to perform:
a. Laparoscopic search for CBD and stone clearance followed by laparoscopic cholecystectomy
b. Open cholecystectomy with open CBD exploration

INTRA-OPERATIVE DIAGNOSIS AND MANAGEMENT OF CBD STONES

Clinical Presentation

Within the following situations the surgeon would like to confirm the presence of typical bile duct stones.
• Pre-operative biochemical tests show marginally raised bilirubin or alkaline phosphatase.
• Mild dilatation of the common bile duct, but the budget not seen well on ultrasonography.
• Recurrent attacks of jaundice inside a patient with multiple gall stones and when pre-operative USG / MRCP / bilirubin is normal.
• Wide cystic duct observed during laparoscopic dissection.

Diagnosis

Intra operative proper diagnosis of cbd stones can be created by
a. Intra operative laparoscopic cholangiogram or
b. Intra operative laparoscopic ultra sonography

Intra surgical cholangiogram is easily the most generally performed imaging modality to identify typical duct stones. This method of performing laparoscopic cholangiography is essential as it is the first step if a person needs to go for laparoscopic trans-cystic or common bile duct exploration. Intra operative ultrasound can also be accustomed to detect stones in the common bile duct. For ultrasound of the biliary tree, high frequency probes, in the 7 to 10 MHz range.