腹腔镜胆总管切开术的综合和创新技术：成功完成这种先进操作的手术指南

概要
对肝外胆管良性疾病（EHBD）的手术分为取石术（即胆总管切开术）或转移术（即胆总管空肠吻合术）。由于技术挑战，用于这些手术的腹腔镜方法尚未在世界范围内普及。腹部的右上象限有利于腹腔镜手术，腹腔镜胆总管空肠吻合术是安全可行的。在这里，作者总结了胆总管切开术的实际过程中的提示和陷阱。腹腔镜胆总管切开术与转导切口和经囊C管引流的一期闭合具有良好的临床效果;但是，无需内镜下括约肌切开术和术前切除麻醉风险因素的急诊胆道引流是必需的。弹性缝合线不应直接结扎在胆囊管上。间断缝线放置是EHBD附近止血的首选。为了防止EHBD的逐渐撕裂，在切换切口的上边缘和下边缘处放置全层间断缝合线。胆管镜检查只有双向手术;使用专用镊子无创地掌握胆管镜对于智能操纵非常重要。术中结石清除的持续时间占手术时间的大部分时间。此外，专用钳是无创伤治疗胆管镜的重要工具。胆管镜损坏需要昂贵的维修费用。用于胆总管切开术的腹腔镜方法涉及技术困难。我希望这份带有视觉解释和文献综述的文件能为熟练的外科医生提供信息。

关键词：腹腔镜手术，胆总管切开术，胆管，腹腔镜，普外科
核心提示：腹部右上腹对腹腔镜手术有利。腹腔镜胆总管切开术是安全可行的，尽管这种腹腔镜手术涉及技术上的困难。内镜下括约肌切开术破坏了Oddi括约肌的生理功能。腹腔镜胆总管切开术具有良好的临床效果;然而，术前需要紧急胆道引流和麻醉风险因素的消除。胆管造影切除结石会严重影响手术时间。胆管镜检查只有双向手术;使用专用镊子无创地掌握胆管镜对于智能操纵非常重要。

介绍
腹腔镜手术已被各个领域采用[1-8]。与开放手术相比，腹腔镜手术具有显著的优势，包括减少失血，减少疼痛，降低发病率，缩短术后饮食时间，缩短住院时间，早期重新融入社会并节省适度成本[1,4,9-13]。腹腔镜手术不需要先进的技术，如吻合口重建或淋巴清扫术（如阑尾切除术，胆囊切除术，远端胰腺切除术和直肠固定术）[3,5-7]有快速的学习曲线[11]。因此，腹腔镜手术在全世界广泛用于良性疾病[5,7]。

不幸的是，腹腔镜肝胆和胰腺（HBP）手术由于技术挑战和旷日持久的学习曲线而发展缓慢[9,14]，腹腔镜胆囊切除除外[15,16]。急性胆管炎（胆总管结石）本身就是一种良性疾病，但相关的胆管静脉回流和随后的败血症很容易导致危及生命的情况[17-19]。肝外胆管良性疾病（EHBD）的外科治疗根据其治疗目的分为截石术（即胆总管切开术）或转移术（即胆总管空肠吻合术）[20,21]。普通外科医生不进行腹腔镜手术，因为它们需要先进的技术和解剖学精度[22-26]，尽管腹腔镜手术对于胆总管切开术和胆总管空肠吻合术是安全可行的[22,25-31]。

开放手术所需的基本技能明显不同于腹腔镜手术[7,8,14,32-34]。值得注意的是，单凭经验并不足以确保腹腔镜手术的成功表现[7,8,14,32-24]。作者在此基于对重要研究和作者自己的经验的回顾，重点介绍了胆总管切开术的腹腔镜方法，总结了这种先进手术的技巧和缺陷。此外，还仔细审查了该领域的重要先前文件。

胆系统的解剖学识别
胆系统的解剖结构如图1A-A所示。肝总管（CHD），胆总管（CBD）和胰管内胆管组成EHBD。胆囊管包含Heister瓣膜（螺旋褶皱）。胆囊漏斗和胆囊管相遇形成漏斗 - 胆囊管结。冠心病，胆囊管和CBD共同构成胆道汇合。胆道引流在生理上受Oddi括约肌的调节。


图1
腹腔镜胆总管切开术的胆道系统和实际手术程序。A：肝总管（CHD），胆总管（CBD）和胰管内胆管构成肝外胆管。胆道引流由Oddi括约肌调节。对胆管造影的Hjortsjo曲线的识别对于检测右肝管的后支是有用的; B和C：胆囊底部被上颚抬起（绿色箭头）。目标站点是Calot三角（蓝色阴影区域）。主外科医生的两个钳（红色箭头）形成从相机端口到Calot三角（蓝色虚线箭头）的轴线的适当角度（大约45°-60°）（红色虚线箭头）。灵活的腹腔镜提供从上前侧（橙色箭头），顺行到视觉监视器的俯视图; D：从左矢状裂到胆囊的U形线的底部平台，必然涉及CHD; E：Rouviere沟始终涉及右肝管; F：识别胆囊管的较白变色，并且在胆囊管和CHD之间产生更宽的角度（红色箭头）。CHD：肝总管; CBD：胆总管。

急性梗阻性化脓性胆管炎
Charcot于1877年首次记录了急性胆管炎[35]; Charcot三联症（上腹痛，发热和黄疸）被提议用于诊断急性胆管炎[36,37]。阻塞引起的胆道停滞[例如，结石，肿瘤，肝功能衰竭或Oddi括约肌功能障碍（DOS）]或胆管压力增加的细菌感染容易导致胆管静脉回流和随后的败血症[17,18]。 Reynolds和Dargan在1959年将Charcot三联征，嗜睡（或精神错乱）和休克状态的临床综合征归类为急性阻塞性胆管炎[38]。此后，这五种症状被称为雷诺五联征[39]。 Reynolds和Dargan认为治疗这种严重胆管炎的唯一方法是急诊手术和胆道引流术[38]。 Longmire于1971年首次将严重的胆管炎定义为Reynold's 五联征，作为急性阻塞性化脓性胆管炎（AOSC）[40]。 AOSC的高死亡率（8％-71％）已被证实[41-44]。

AOSC常见于老年患者[42,44];这些患者需要急诊胆道引流[19]。介入内镜医师可选择内镜下括约肌切开术（EST）。 EST破坏了Oddi括约肌的生理功能，即使是在具有微妙DOS的老年患者中也是如此。这种情况提出了一个简单的问题。 EST是急诊胆道引流的首选，即使是年轻患者也是如此？单独EST不需要作为初始治疗[45]，作者不应忘记EST会破坏Oddi括约肌的生理功能。 EST后，Oddi's括约肌的生理功能恢复是不可能的。为了保持生理功能，选择性手术优于紧急EST;没有EST的经皮胆道引流可以最初作为紧急治疗进行[45]。

急性胆管炎和胆管结石
对胆管结石急性胆管炎的初步处理已被记录[19,45];胆道引流应尽快在这些患者中进行[19]。急性胆管炎胆道引流的临床适应症和治疗技术已经明确[45]。内镜下经鼻胆管引流，无论是通过鼻胆管引流还是胆道支架术，都应选择一线治疗[45]。由于担心出血，EST不是常规推荐用于胆道引流术[45]。

DOS和解剖异常（例如，壶腹周围憩室）导致急性胆道感染，并随后引起原发性胆管结石[46]。术前应确认胆管结石的病因。在伴有胆管结石的患者中，可以通过内窥镜方法（例如，EST，乳头扩张和气囊小肠镜辅助和/或超声引导方法）[45]或手术治疗[47-49]进行结石切除。腹腔镜胆总管切开术被认为是一种安全可行的治疗选择[22,26-28,31]。如上所述，AOSC经常发生在老年患者中[42,44];甚至在这个人群中也应该选择腹腔镜手术。

对于术前病情稳定的患者，急诊和择期腹腔镜手术均安全可行[50]。围手术期镇痛药很重要;然而，一些镇痛药（如阿片类药物或吗啡）会引起药物诱导的DOS [51,52]。应在术前实现有效的胆汁引流以避免脓毒症[19,45]，因为应该竞争消除全身麻醉的危险因素（例如，不稳定的血液动力学状态，阻塞性黄疸，败血症和镇痛禁忌症）[53-55]。

腹部手术后胆管结石和相关胆管炎
急性胆管炎和胆管结石是腹部手术后的关键问题，尤其是老年患者[28,56,57]。胃切除术通过手术改变胆道系统，因为淋巴结和神经的不可避免的解剖导致生理障碍（例如，DOS，胆汁分泌减少，失调性胆囊和麻痹性肠）[7,58]。因此，胃切除术后很容易发生反复的胆管炎和胆管结石[57,59]。

在重新手术期间，严重粘连和致密组织通常难以治愈。此外，由于消化道吻合术和术后粘连，重要的导管和血管的位置可能很容易在胃切除术后移位，特别是在Billroth I重建[7]。然而，腹腔镜手术即使对于胆囊切除术也是有利的[28,59]，即使在复杂腹部手术后的老年患者中也是一种安全，有效和可行的治疗方法[56]。如果以Roux-en-Y方式进行胃空肠造口术，可选择腹腔镜胆总管十二指肠吻合术（非胆总管空肠吻合术）作为替代治疗[57,60]。腹腔镜胆囊切除术应该是有腹部手术病史的患者胆囊结石和胆囊炎的首选[7,8,61]，尽管EST术后胆囊切除术治疗胆管结石并不能降低复发性胆管炎的发生率[62]。

胆囊切除术和胆汁排泄的历史
1892年，阿贝在胆总管切开术后首次进行胆管引流术[63,64]; Deaver在1904年报道了使用改进的T型管引流管[63,64]。凯尔在1909年提出了T型管引流的有用性[63-67];此后，胆总管切开术后的转导T管引流在全世界普遍使用。 T管的材料很重要，因为EHBD或腹膜腔中的低反应导致由于材料惰性导致管周围缺乏组织管形成[63,64]。各种硫化橡胶产品可由天然橡胶和硫磺生产。硫化程度会影响所得橡胶的硬度和刺激性[64]。红色橡胶是最刺激性的，硅橡胶是最少的[63,64,68]。乳胶橡胶管是长期引流的首选，因为它们可以产生良好的组织管道，因为组织反应可以抵抗材料的刺激[63,64]。硅橡胶T管通常不能引起组织管形成[63,64,68]。应选择红色或乳胶橡胶作为T型管材料[63,64,68]。

急性胆管炎可以通过经胸胆管引流，EST，转导引流（T管）或经囊引流（C管）来控制[22]。与其他治疗方案相比，Transductal T管引流具有更高的结石清除率和胆漏率[22]。 EST的手术发病率较高，可能会出现严重后果[22]。 Transcystic C管引流是一种易于使用的技术，简化了外科手术，并发症发生率低于其他治疗方法[22]。通过常规开放手术切除T管引流与腹腔镜一期闭合与经囊C管引流的胆总管切开术的选择仍存在争议[69]。目前，腹腔镜胆总管切开术与原发性闭合和经囊C管引流优于常规开放式手术导管T管引流[69]，这促使HBP外科医生终止使用转导性T管引流术[47,49,70] ]。

ODDI's 括约肌生理功能的有意保存
EST破坏Oddi括约肌的生理功能，而EST后，Oddi括约肌的生理功能恢复是不可能的。尽管急诊EST比选择性腹腔镜手术更容易，但没有EST的经皮胆道引流是急性胆管炎的初始治疗[45]。 EST的完成导致Oddi括约肌的生理功能的破坏。应该避免考虑使用EST [20]，尽管许多医生可能会认为反对EST的论点确实有限。为了保留括约肌功能，应该在特殊情况下进行紧急EST（例如，患有严重合并症，严重疾病，长期黄疸或以前手术引起的严重DOS的老年患者[20,71]。矛盾的是，EST可能是患者允许的谁已经有DOS。例如，老年人或术后患者可能有严重的DOS [7,57-59]。

复发性结石和相关胆管炎
胆总管切开术或EST后胆管中的复发性结石（非残留结石）是另一个关键问题[20,57,72]。手术或内镜治疗后的早期结石复发对于医生来说是一个可怕的事件[20,57]。虽然腹腔镜胆总管切开术为复发性结石和相关性胆管炎提供了安全可行的治疗[28,30,56,59]。

如上所述，DOS，胆汁分泌减少和麻痹性肠道引起对复发性结石和相关胆管炎的担忧;完全切除胆管结石后选择性腹腔镜胆囊切除术不会降低重复性胆管炎的复发率[62]。应仔细评估胆管结石的病因，并根据确定的或建议的病因选择治疗策略。尽管针对胆管结石的内镜治疗的论点可能非常有限，腹腔镜胆总管切开术即使对于复发性结石也是一种安全可行的治疗方法[28,30,56,59]，腹腔镜胆总管空肠吻合术可能是一种可能的治疗方案，胆道转移可根据生理障碍进行治疗。[20,30]

胆管结石的术前评估
应该在没有任何残余石块或碎片的情况下实现石头间隙[73]。包括内窥镜和钳在内的专用器械对于成功摘除外科手术至关重要[74,75]。一些结石（例如受影响的，多发性或肝内结石）的清除涉及技术挑战[76]。石头移除的持续时间对手术时间有很大影响[73,74];详细的术前影像学研究缩短了手术时间[77]。移除受冲击的和/或大的结石尤其困难[27,73]，尽管即使受影响的结石在术前胆道引流后仍会漂浮[76]。强烈建议采用内镜逆行胆管造影术或胆管造影术进行术前评估[78]。术前还应排除导致DOS和禁忌EST的十二指肠旁乳头憩室的存在[79]。

EHBD腹腔镜手术的技术难点
胆囊结石伴急性胆囊炎是手术的适应证[7,8,80];炎症严重程度可能是这些病例的重要危险因素[81,82]。 EHBD的外在压迫，包括Mirizzi综合征和隐藏的胆囊管，使腹腔镜胆囊切除术在技术上很困难[81,83]。然而，关键的安全观（即胆囊管和动脉的阳性鉴定）的概念已于1995年确立[34]。符合该协议使腹腔镜胆囊切除术即使在严重的胆囊炎中也是安全的[7,8]。在腹腔镜手术中，右上象限为手术区域提供了合适的位置[7,30,84]，这也是腹腔镜胆囊切除术在全球范围内传播的一个原因[15,16]。腹腔镜胆囊切除术中可靠的稳定性对于成功的腹腔镜胆总管切开术是必不可少的[7,8,32,34,81]。

然而，技术挑战阻止了EHBD（例如，胆总管切开术和胆总管空肠吻合术）的腹腔镜手术在世界范围内的普及[22,23]。这些先进的外科手术应该由熟练的HBP外科医生掌握[24,25]。尽管腹腔镜胆总管切开术和胆总管造口术[22,25-31]是安全可行的，但技术挑战阻碍了这些晚期HBP手术的全球传播[22-26]。

腹腔镜胆囊切除术的实际手术方法
患者处于仰卧位。通过脐带端口实现10至12mmHg的二氧化碳气腹。经导管切口伴有胆汁流出，胆管镜检查需要连续的盐水流量进行腔内观察。使用盐水冲洗器和抽吸尖端（StrykeFlow，Stryker Co.，Kalamazoo，MI，United States）。在腹腔镜胆总管切开术中需要频繁，连续抽吸，尽管抽吸导致气腹塌陷。在腹腔镜手术期间，气腹稳定性对于维持手术区非常重要[85]。因此，作者采用自动维持的气腹系统（AirSeal Intelligent Flow System，Conmed Co.，Utica，NY，United States）。需要具有足够光源的柔性腹腔镜（Endoeye Flex，Olympus，Tokyo，Japan）;腹腔镜手术在各种角度视图下进行。

上腹部共有四个工作口。一名助理外科医生腹部收缩胆囊底部。目标站点是Calot三角;主外科医生的两个钳子相对于从摄像头端口到Calot三角的轴线形成足够的角度（大约45°-60°）（图（图1B1B和C））。过窄或广角使腹腔镜手术复杂化，包括全内部手术缝合[7]。此外，灵活的腹腔镜提供了从前上方，俯视到视觉监视器的俯视图（图1B1B和C）。因此，右上象限非常适合外科手术的设置[7,30,84]。如果需要，外科医生应该毫不犹豫地放置额外的端口，因为刺伤是微创的[7]。

肝脏被一个位于剑突下方的蛇形牵开器抬起。肝十二指肠韧带拉伸良好[7]。肝肾窝广泛扩张，获得工作空间。从左矢状裂到胆囊的U形线的底部高原，必然涉及CHD（图（图1D），1D）和Rouviere沟，它总是涉及右肝管（图1E） ，1E），经常被确认。

漏斗和胆囊管交界处的颜色变化较为明显[7]（图1F）.1F）。胆囊管和CHD之间的角度加宽，以防止由这些胆管的平行连接引起的隆起损伤[7,32,34,81,86]（图（图1F）.1F）。安全性的关键观点建立在前部（图（图2A）2A）和后部（图（图2B））[33,87]。


图2
腹腔镜胆总管切开术的实际外科手术。 A和B：在前部（A，箭头）和后部（B，箭头）方面建立了关键的安全性观点; C：在胆囊管中制作半圆形切口; D：Heister瓣被小心摧毁; E：去除胆囊管中的结石; F：金黄色胆汁从肝外胆管流出。 C管是插管的。CHD：肝总管; CBD：胆总管。

由二氧化碳气体渗透引起的气腹压力有助于产生可分散的层。为避免意外伤害，应尽可能将可解剖层追踪到尽可能接近胆囊[7]。组织解剖和膜切割应从正确层的可视化侧延伸，而不是从看不见的侧面延伸[7]。然后将胆囊从肝床中取出。

将胆囊管拉直，在胆囊附近的胆囊管上进行半圆形切口（图（图2C）.2C）。切除胆囊完全切除干扰进一步的手术。在将C管放入EHBD（图（图2D）2D）并从胆囊管中取出结石之前，Heister瓣膜被小心地破坏（图（图2E）.2E）。用于破坏Heister瓣的粗心刺伤程序很容易导致胆道汇合或EHBD后壁的严重损伤。金黄色胆汁从EHBD流出，然后C管插管（图2F）.2F）。 C管可用作胆管造影管，用于术中胆道造影。弹性缝合线不直接结扎，以避免C形管过度拧紧;引流不足会引发术后并发症。使用弹性缝线和夹子完成C管的最佳经蒂固定[7]（图（图3A-C）; 3A-C）;第二个夹可以防止第一个夹[7]的滑动（图（图3D3D））​​。


图3
腹腔镜胆总管切开术的实际外科手术。 A-C：用弹性缝线和夹子完成C管的最佳经蒂固定。弹性缝线永远不会直接结扎; D：第二个夹子防止第一个夹子滑动; E：有意探查肝总管，胆总汇和胆总管; F：应保留肝外胆管周围的喂食和引流血管。CHD：肝总管; CBD：胆总管。

在腹腔镜胆囊切除术中，应该识别CHD，胆道汇合和CBD，但应避免直接暴露这些结构[7,8]。然而，在腹腔镜胆总管切开术中应该有意识地探索这些胆管结构（图3E）.3E）。虽然仔细完成钝性解剖以探查EHBD的壁，但是良性胆道疾病不需要故意解剖胆道恶性肿瘤的自主神经[88,89]。应保留EHBD周围的滋养和引流血管，以防止导管坏死和术后胆漏（图3F3F）[7] .EHBD开放时有清晰的解剖（图（图4A）; 4A）;能量装置不应该是使用，以避免轻微的热损伤。在出血点放置体内缝线和随后的结扎是胆管壁附近止血的首选（图4B）.4B。如果渗透是前壁顽固EHBD，带有吸力的纽扣形电极与软凝固系统（VIO，Erbe，Tübingen，德国）一起使用是安全止血的有效工具。在EHBD打开后，EHBD的内腔是充分冲洗以提高胆结石（图（图4C）.4C）。此后，所有结石被完全切除[90]（图（图4A4D））。


图4
腹腔镜胆总管切开术的实际外科手术。A：肝外胆管（EHBD）开放时有清晰的解剖; B：体内缝线放置和随后的结扎是止血的首选。不应使用能源设备; C：EHBD的腔体被充分冲洗。在腹腔镜胆总管切开术中需要频繁连续抽吸。自动维持的气腹系统用于保持足够的手术区域; D：除去所有的石头; E：放置间断的缝合线，然后在导管孔的上边缘和下边缘处结扎，以防止由胆管镜操作引起的进行性撕裂。此后，双侧放置固定缝合线（蓝色箭头）以打开换能孔。这些固定缝合线在腹腔镜套管针的不同位置通过腹壁充分固定; F：将间断的缝线和随后的结扎置于转导切口的上边缘和下边缘，以防止由于胆管镜操作引起的进行性撕裂。CHD：肝总管; CBD：胆总管; EHBD：肝外胆管。

在沿着长轴的换能切口之后，将中断的可吸收单丝缝合线（PDS II，4-0，紫罗兰，SH-1，Ethicon Inc.，Bridgewater，NJ，美国）放置在所述层的上边缘和下边缘处。切口以防止由后续手术引起的进行性撕裂，包括胆管镜操作（图4E4E和F）。此后，体外缝线双侧放置可吸收单丝缝合线（PDS II，4-0，紫罗兰，SH-1,90 cm， Ethicon Inc.）作为固定缝合线打开导管孔（图5A5A和B）。这些固定缝合线通过腹壁适当地设置在腹腔镜套管针与套管针部位闭合装置的不同点（Endo Close; Medtronic，爱尔兰都柏林）（图（图5C5C））。


图5
腹腔镜胆总管切开术的实际外科手术。 A和B：双侧放置固定缝合线（蓝色箭头）以打开导管孔; C：在具有套管针部位闭合装置的腹腔镜套管针的不同点处，通过腹壁充分地固定缝合线。用蛇形牵开器将肝脏头部抬起以拉伸肝十二指肠韧带; D：专用的弹性钳对于成功的腹腔镜胆总管切开术非常重要。钳子的尖端包含硅胶垫以避免损坏胆管镜。 Olympus（A66070A;日本东京）和Karl Storz Endoskope（K33531 PG; Tuttlingen，德国）分别提供定制钳; E和F：应确认肝总管侧肝管的分叉（E）和胆总管侧（F）的胰管内末端的特征性发现。在转导切口的上边缘和下边缘处的间断结扎防止在胆管镜操作期间的渐进性撕裂（红色箭头）。固定缝合线（蓝色箭头）被移除。冠心病：肝总管; CBD：胆总管。

应彻底清除溢出的结石和/或感染的胆汁[90]。通过腹腔镜套管针进行术中胆管镜检查对腹腔镜胆总管切开术至关重要。专用的弹性钳可以充分抓住胆管镜，而不会损坏特殊涂层，并允许胆管镜进行石头移除（A66070A，10 mm，Olympus或CLICKline BERCI，K33531 PG，10 mm; Karl Storz Endoskope，Tuttlingen，德国）成功进行腹腔镜胆总管切开术的关键工具（图（图5B）.5D）。使用传统腹腔镜钳直接抓握会对内窥镜表面造成无法修复的损伤，应予以避免。应通过胆管镜仔细观察腔内发现。 CHD侧双侧肝管分叉（图（图5E）5E）和CBD侧胰腺内胆管末端的特征性发现（所谓的“肌动蛋白”）（图（图5F）5F）应该得到确认。

EHBD的直径一般> 10 mm [31];根据EHBD直径[91-93]选择转导切口的一次闭合方法。通常，导管切口闭合和随后的主要闭合都沿着长轴在相同方向上进行（图6A）.6A）。在EHBD直径小于7至8 mm的情况下，在短轴方向上进行一次闭合以避免术后狭窄（图6B）.6B）。转导切口主要通过体内结扎封闭，其中可吸收单丝缝线的主要全层间断缝线（PDS II，5-0，紫罗兰，RB-1; Ethicon，Inc。）。


图6
腹腔镜胆总管切开术。A：一般来说，导管切口和随后的主要闭合都沿着长轴在相同的方向上进行; B：在直径小于7-8 mm的导管中，沿短轴方向进行一次闭合，以避免术后狭窄; C和D：虽然重复手术期间严重的粘连和致密组织通常难以治愈，但腹腔镜手术对于胆总管切开术是安全可行的; E和F：沿着长轴制作转导切口（蓝色箭头），并且在切除切口的上边缘和下边缘处放置全层间断缝线，以避免在胆管镜操作期间肝外胆管严重撕裂。CHD：肝总管; CBD：胆总管。

最后，使用造影剂和无毒染料（靛蓝胭脂红或吲哚青绿）通过C管进行实时术中胆管造影。残留的结石，胆漏和通道阻塞都经过仔细检查。在手术期间评估胆道，尤其是通过主闭合部分和Oddi括约肌的胆道。通常进行腹腔内灌洗和引流管放置;手术后监测排出物中的总胆红素水平。

腹腔镜胆囊切除术中避免EHBD和CYSTIC DUCT的误诊
在有剖腹探查病史的患者中，严重的粘连和致密组织通常难以治愈（图6C6C和D）。此外，重要的导管和血管的位置可能会发生变化。术中识别“第二胆囊管”或“副导管”强烈表明胆囊和CHD的错误识别[32]。术中胆道造影是检测这种错误识别的推荐解决方案[32]。识别Hjortsjo曲线是检测右肝管分支的有效方法[7]。虽然没有常规胆管造影证据[34]，但腹腔镜外科医生在指出时应该毫不犹豫地进行术中胆管造影[94-98]。

专科医生在腹腔镜胆囊切除术中充分操作胆管镜的重要性
术中胆管镜检查是观察腔内发现和去除结石的重要手术。应该避免令人沮丧的程序。术中结石清除的持续时间占手术时间的大部分时间。胆管镜检查只有双向手术。因此，专门用于无创地抓住胆管镜的钳子是智能胆管镜操作和成功的腹腔镜胆总管切开术的关键工具。传统的腹腔镜钳对胆管镜的表面涂层造成严重损害。即使轻度损坏也需要非常昂贵的维修，可能达到近10000美元。 Olympus（产品标准号：A66070A）和Karl Storz Endoskope（产品标准号：K33531 PG）分别提供定制镊子。作者使用的实际镊子如图5D.5D所示。沿长轴进行转导切口（图6E）.6E）。此后，全层间断缝线应放置在转导切口的上下边缘（图6F），6F），因为胆管镜操作很容易引起EHBD沿其长轴的严重撕裂。

在胆管周围发生意外的热损伤
烧伤引起的损伤导致导管和/或血管周围组织的坏死性丧失[32]。烧灼，腹腔镜凝固剪切和较强的装置可能导致相邻结构的热坏死[32,99]，并可能随后导致热损伤延迟[100]。这种热损伤的扩散导致手术后的胆道并发症[7]。应仔细保护EHBD表面上的开发容器免受热损伤[7]。最小化间断缝合和结扎是在胆管壁附近实现止血的首选（图4B）.4B）。如果使用额外的缝合线无法安全止血，可以允许带有抽吸的按钮形电极和软凝固系统（VIO，Erbe）用于EHBD附近的止血。

腹腔镜胆囊切除术后的临床管理
术后第4天进行初始胆管造影，根据胆管造影的目的调整造影剂。对于术中胆道造影，使用含有无毒染料的全浓度造影剂来检测甚至微小的渗漏和狭窄。没有染料的半浓度造影剂用于术后胆管造影，因为完全浓缩可能会隐藏小石头。然后根据胆管造影结果和正在进行的胆管引流需要移除C管[7]。 C管引流管理简单;使用所谓的“交会技术”，通过导管通过C管[101-103]使用内窥镜插管术，可以很容易地用经腋下胆管引流代替经引流术。相比之下，导管T管引流不可避免地要求引流管放置至少3周[65,66];长期引流会导致电解质异常，消化紊乱，腹泻和脱水。难以摄入自体胆汁（即排出的胆汁）[104,105]。而且，T管放置的排放量是繁重的。

讨论
用于良性疾病的腹腔镜HBP手术具有几个优点，包括优异的放大可视化和位于身体右前侧的足够的手术区域[7,30,84]。腹腔镜外科医生应该精通各种技术和设备[6,14];腹腔镜胆总管切开术需要熟练操作钳子[30]。这种先进的手术在临床环境中是可行的[7,30,84]。即使急性胆管炎患者急需内镜下经皮胆管引流术[19,45]，随后的腹腔镜HBP手术治疗EHBD良性疾病也具有良好的临床疗效和可接受的疗效[22,26-28,31]。

与常规开放式T管引流术相比，腹腔镜胆总管切开术采用经囊内C管引流术，结石清除率高，胆漏少，出血少，死亡率和发病率可接受，住院时间缩短，早期重新融入社会[ 22,27,69,106-109。然而，在腹腔镜手术中，手术时间延长，成本变得更高[110,111]。总的来说，作者永远不应该忘记腹腔镜胆总管切开术和经囊内C管引流术是EHBD胆管结石的首选。

严重急性胆管炎和AOSC容易导致败血症[17,18];老年人口是AOSC的目标[42,44]。急诊胆道引流对危及生命的患者至关重要[19]。为了保持Oddi括约肌的生理功能，应该避免考虑使用EST [20]。 HBP外科医生应该努力结束传导的开放式手术，采用导管T管引流术[47,49,70]。腹部右上腹为腹腔镜HBP手术提供了足够的空间[7,30,84]。一期腹腔镜胆总管切开术具有良好的临床效果[22,26-28]和成本效益[112,113]，即使急诊胆道引流可预防脓毒症[19,45]并完全切除全身麻醉的危险因素[53-55] ] 是必要的。

机器人手术在HBP手术领域提供了一个有前途的前沿[114-116];然而，腹腔镜手术对于EHBD的良性胆道疾病是安全可行的[22,25-30,84]。近几十年来，腹腔镜手术得到了很好的发展，特别是在HBP手术领域。 EHBD中的胆道结石是一种常见疾病，腹腔镜胆总管切开术是一种常规手术，目前在许多中心都没有这种技能要求。然而，特别是在日本，腹腔镜胆总管切开术不是常规手术，尽管有医疗保险的覆盖[117,118]，许多医生宽恕考虑使用EST治疗胆道结石[20]。在此，详细描述了腹腔镜胆总管切开术的实际手术，并且表11中总结了该高级手术的重要文献。作者希望作者的文章能够通过视觉解释和文献综述为熟练的HBP外科医生提供信息。

EHBD: 肝外胆管; EST: 内镜下括约肌切开术; HBP: 肝胆胰腺。

结论
腹腔镜胆总管切开术不是火箭科学。安全的腹腔镜HBP手术是EHBD良性疾病的推荐方法。我希望这篇文章能为这些患者带来益处。

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