目的：总结腹腔镜胆总管囊肿切除肝管空肠Roux－en－Y吻合手术经验。方法2011年1月～2013年12月，采用腹腔镜技术治疗先天性胆总管囊肿69例，年龄2个月～14岁，平均3．5岁。三孔法12例，四孔法57例。利用右上腹trocar完成胆道造影，5 mm 30°腹腔镜下胆囊和胆总管囊肿壁全层切除；利用腹腔镜镜头探查扩张的肝内胆管；从脐部1．5 cm切口提出空肠，腹外行空肠吻合；还纳空肠肠管；经脐部切口提出横结肠，于横结肠系膜打孔上提空肠的肝支，还纳横结肠，镜下用4－0 Quill线将肝管与空肠端侧连续吻合。结果中转开腹5例，原因主要为1例肝总管无狭窄但过细，肝管分离，存在副肝管，4例囊肿巨大且囊肿炎症重尤其胰腺段过长。64例腹腔镜下完成手术，手术时间180～380 min，平均225 min，术中出血5～20 ml。术后出血2例，均经保守治疗痊愈。胆肠吻合口漏2例，经腹腔引流痊愈。2例术后2个月和6个月因系膜裂孔内疝导致肠梗阻，均急诊手术解除。其他58例腹腔镜术后恢复顺利，术后住院时间4～21 d，平均6．8 d。64例术后随访4～42个月，平均23．6月，肝功能正常，无结石和胰腺炎发生。结论腹腔镜胆总管囊肿切除肝管空肠Roux－en－Y吻合术需要严格掌握适应证，术者需要有熟练的开放手术经验和腹腔镜操作技巧，稳定的手术团队是也确保手术成功的关键。%Objective To review the experience of laparoscopic total cyst excision with Roux-en-Y hepatoenterostomy for choledochal cyst in children . Methods A retrospective analysis of 69 patients who had undergone laparoscopic choledochal cyst excision from January 2011 to December 2013 was carried out.The patients’ average age was 3.5 years old (2 months-14 years). The surgery was performed by using three-port method in 12 cases and four-port method in 57 cases.The cholangiography was conducted via the upper right abdominal trocar .Under a 5 mm 30°laparoscope, the gallbladder and the dilated bile duct were completely excised and the intrahapic bile ducts were examined for stone debris and ductal stenosis .Laparoscopic cyst excision and ductoplasty was performed if the patient was associated with hepatic ductal stenosis .After exteriorization of the small bowel through the umbilical 1.5 cm incision, a Roux-en-Y anastomosis was performed .Then the bowel was reintroduced into the abdominal cavity and a laparoscopic end-to-side hepaticojejunostorny was carried out by continuous hand suture method between the stump of the hepatic duct and Roux-en-Y limb. Results Sixty-four patients successfully underwent laparoscopic choledochal cyst resection , while 5 patients were given a conversion to open surgery because of excessive small hepatic duct and existence of accessory hepatic duct in 1 case and inflammatory huge cysts with long pancreatic branches in 4 cases.The mean operation time of the 64 patients was 225 minutes (range, 180-380 minutes).The intraoperative bleeding volume was 5-20 ml.Postoperative bleeding occurred in 2 cases, which were cured by expectant treatment .The bile leakage occurred in 2 cases and was cured by drainage .Intestinal obstruction occurred in 2 cases because of intra-abdominal hernia in mesenteric hiatus at 2 and 6 months after the surgery ,respectively ,and was cured by emergencey operation.The other 58 patients were recovered smoothly , with a hospital stay of 4-21 d (mean, 6.8 d) after the operation.All of the 64 patients had been followed up for 4 -42 months (mean, 23.6 months), which showed normal hepatic functions and no biliary stones or pancreatitis . Conclusions Performance of laparoscopic total cyst excision with Roux-en-Y hepaticojejunostomy should n strictly follow the indications .The keys of successful operation lie on not only surgical experiences and techniques , but also a stable operation team.
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