CAJ | 학술논문

目的：探讨对腹腔镜胆囊切除术（ laparoscopic cholecystectomy ，LC）中隐匿性胆总管结石行微创治疗的可行性。方法2007年7月～2012年5月对27例LC术中发现的隐匿性胆总管结石采用微创治疗。胆囊管内径＞5 mm者经胆囊管胆道镜取石；胆总管内径＞6 mm者行胆囊管汇入胆总管处微切开后胆道镜取石，一期缝合或留置造影管；胆囊管内径≤5 mm、胆总管内径≤6 mm者直接留置造影管，术后再次造影，必要时行十二指肠镜乳头括约肌切开（ endoscopic sphincterotomy ，EST）取石。结果手术均获成功。8例直接经胆囊管胆道镜取石；11例行胆囊管汇入胆总管处微切开后胆道镜取石，一期缝合7例，留置造影管4例，1周后造影均阴性；8例直接留置造影管，1例术后36 h滑出，1周后ERCP造影胆囊管残端无渗漏，EST取石，术后1周再次造影3例结石消失，4例仍有结石，均经EST取出。无出血、胆漏、腹腔感染等并发症。24例随访6～24个月，平均16个月，无结石残留、胆管狭窄及胆管炎发生。结论熟练运用腹腔镜、胆道镜、十二指肠镜技术，对LC术中发现的隐匿性胆总管结石实施微创治疗是安全、可行的。
목적：탐토대복강경담낭절제술（ laparoscopic cholecystectomy ，LC）중은닉성담총관결석행미창치료적가행성。방법2007년7월～2012년5월대27례LC술중발현적은닉성담총관결석채용미창치료。담낭관내경＞5 mm자경담낭관담도경취석；담총관내경＞6 mm자행담낭관회입담총관처미절개후담도경취석，일기봉합혹류치조영관；담낭관내경≤5 mm、담총관내경≤6 mm자직접류치조영관，술후재차조영，필요시행십이지장경유두괄약기절개（ endoscopic sphincterotomy ，EST）취석。결과수술균획성공。8례직접경담낭관담도경취석；11례행담낭관회입담총관처미절개후담도경취석，일기봉합7례，류치조영관4례，1주후조영균음성；8례직접류치조영관，1례술후36 h활출，1주후ERCP조영담낭관잔단무삼루，EST취석，술후1주재차조영3례결석소실，4례잉유결석，균경EST취출。무출혈、담루、복강감염등병발증。24례수방6～24개월，평균16개월，무결석잔류、담관협착급담관염발생。결론숙련운용복강경、담도경、십이지장경기술，대LC술중발현적은닉성담총관결석실시미창치료시안전、가행적。
Objective To evaluate the feasibility of minimally invasive therapy for occult choledocholithiasis during laparoscopic cholecystectomy (LC). Methods From July 2007 to May 2012, we performed minimally invasive therapy for occult choledocholithiasis during LC in 27 cases.If the cystic duct diameter was more than 5 mm, the calculi were removed via the transcystic approach by choledochoscopy .If the common bile duct diameter was exceeding 6 mm, transcystic exploration was performed for stone removal after micro-incision of the cystic duct , and then the cystic duct was primarily sutured or a catheter was left after removal of the calculi.If the cystic duct diameter was less than 5 mm and the common bile duct diameter was less than 6 mm, a cholangiogram catheter drainage was carried out directly for repeated cholangiography at 1 week postoperatively .Endoscopic sphincterotomy ( EST) was carried out , if necessary . Results All the operations were performed successfully .The calculi had been removed via the transcystic approach by choledochoscopy in 8 patients.Stone removed by choledochoscopy after micro-incision of the cystic duct was performed in 11 patients, 7 of which were primarily sutured and 4 of which were left a catheter,and all of which had a normal cholangiogram at 1 week postoperatively .In another 8 patients, cholangiogram catheter was left directly .The cholangiogram catheter was detached at 36 hours postoperatively in one patient .There was no retained cystic duct bile leakage under ERCP 1 week later, and persistent common bile duct calculi was retrieved by EST .Three patients had a normal cholangiogram at 1 week postoperatively .Only 4 patients had persistent common bile duct calculi at 1 week after LC and retrieved by EST .No hemorrhage , biliary leakage , or abdominal infection occurred after the treatment .The 24 patients were followed up for 6-24 months with a mean of 16 months, during which no residual stones , biliary stenosis , or cholangitis were observed . Conclusion With experienced using laparoscopy and choledochoscopy combined with duodenoscopy , minimaly invasive therapy can be safe and feasible for patients who have occult choledocholithiasis during LC .