單向倒刺線(xiàn)在腹腔鏡膽道探查膽總管一期縫合術(shù)中的對(duì)照研究

段 鍵，楊世昆，夏仁品，林 杰，黃漢飛，徐王剛，曾 仲

(昆明醫(yī)科大學(xué)第一附屬醫(yī)院肝膽外二科 650032)

論著·臨床研究 doi:10.3969/j.issn.1671-8348.2017.04.015

單向倒刺線(xiàn)在腹腔鏡膽道探查膽總管一期縫合術(shù)中的對(duì)照研究

段 鍵，楊世昆，夏仁品，林 杰，黃漢飛，徐王剛，曾 仲△

(昆明醫(yī)科大學(xué)第一附屬醫(yī)院肝膽外二科 650032)

[摘要] 目的 探討單向倒刺縫線(xiàn)在腹腔鏡下膽道探查膽總管一期縫合術(shù)中應(yīng)用的安全性及有效性。方法 回顧性分析該科室2013年1月至2015年8月109例患者，其中使用免打結(jié)倒刺線(xiàn)與普通縫線(xiàn)行腹腔鏡膽總管一期縫合術(shù)，比較患者手術(shù)時(shí)間、膽道縫合時(shí)間、并發(fā)癥及術(shù)后恢復(fù)情況。結(jié)果 傳統(tǒng)縫線(xiàn)68例,單向倒刺縫線(xiàn)41例。所有患者手術(shù)均成功,普通縫線(xiàn)組1例出現(xiàn)手術(shù)并發(fā)癥,為術(shù)后有少量膽漏,經(jīng)腹腔引流管充分引流后治愈。倒刺線(xiàn)組無(wú)并發(fā)癥。兩組患者術(shù)后膽道并發(fā)癥發(fā)生率(P=0.603)、術(shù)中出血量(P=0.069)，術(shù)后住院時(shí)間(P=0.083)，差異均無(wú)統(tǒng)計(jì)學(xué)意義;膽管切口縫合時(shí)間(P=0.015)；手術(shù)時(shí)間(P=0.023)，倒刺線(xiàn)組均低于傳統(tǒng)縫線(xiàn)組,兩組差異有統(tǒng)計(jì)學(xué)意義。結(jié)論 單向倒刺縫線(xiàn)用于腹腔鏡膽總管一期縫合術(shù)是可行的，可以降低腹腔鏡下縫合難度，縮短縫合及手術(shù)時(shí)間，縮短學(xué)習(xí)曲線(xiàn)，值得推廣。

膽結(jié)石;膽總管;腹腔鏡；縫線(xiàn)

膽總管繼發(fā)結(jié)石是膽囊結(jié)石的主要并發(fā)癥之一，而且其可進(jìn)一步引起梗阻性黃疸、急性膽管炎、膽絞痛、膽源性胰腺炎。目前合并膽囊結(jié)石的膽總管結(jié)石行腹腔鏡下膽總管探查術(shù)(laparoscopic common bile duct exploration，LCBDE)具有治療周期短(一期完成)、安全、有效的優(yōu)點(diǎn)，越來(lái)越受到外科醫(yī)生的推崇[1-2]。目前的不少文章、多中心Meta分析及本科室既往研究均已證實(shí)膽總管切開(kāi)探查后一期縫合具有恢復(fù)快、并發(fā)癥少、費(fèi)用低等優(yōu)點(diǎn)[3-6]。使膽總管探查后一期縫合已在包括本院在內(nèi)的眾多醫(yī)療單位常規(guī)開(kāi)展。本研究探討單向倒刺線(xiàn)在膽總管切開(kāi)探查取石后一期縫合中的臨床應(yīng)用價(jià)值。

1 資料與方法

1.1 一般資料 入選的109例患者，行傳統(tǒng)縫線(xiàn)68例,單向倒刺縫線(xiàn)41例。均符合以下條件：術(shù)前診斷膽囊結(jié)石伴膽總管結(jié)石；排除急性化膿性膽管炎及急性膽源性胰腺炎；術(shù)前影像學(xué)排除肝內(nèi)膽管結(jié)石;膽總管直徑均超過(guò)0.8 cm;術(shù)中膽道鏡探查或膽道造影均證實(shí)結(jié)石已取凈;膽總管黏膜炎癥水腫及管壁增厚程度均為輕度。兩組患者的年齡、性別、術(shù)前膽紅素水平、丙氨酸氨基轉(zhuǎn)移酶(ALT)、天門(mén)冬氨酸氨基轉(zhuǎn)移酶(AST)、膽總管直徑差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)，見(jiàn)表1。

表1 兩組患者基本情況比較±s,%)

1.2 方法 109例患者均是由同一治療組管理，同一主刀醫(yī)師完成手術(shù)。麻醉成功后取仰臥位，頭高足低左側(cè)斜位，常規(guī)消毒鋪單后取臍部切口，插入氣腹針，注入CO2氣體，壓力14 mm Hg，置入10 mm trocar，30°鏡探查腹腔，在腹腔鏡直視下于劍突下置入12 mm trocar，右側(cè)肋緣下置入2個(gè)5 mm trocar。常規(guī)解剖膽囊三角，游離切斷膽囊動(dòng)脈，游離結(jié)扎膽囊管但不予切斷，使其在膽道探查時(shí)起到牽引作用。在十二指腸上方縱行切開(kāi)膽總管,長(zhǎng)度約1.5 cm,膽道鏡探查肝內(nèi)外膽道并取凈結(jié)石,確認(rèn)膽總管下端通暢,Oddi 括約肌收縮功能正常。(1)倒刺線(xiàn)組:4-0 V-lock180(Covidien)線(xiàn)連續(xù)全層縫合膽總管切口;(2)普通縫線(xiàn)組：4-0 VICRYL Plus,CR/8(Ethicon)線(xiàn)間斷全層縫合膽管切口?？p合膽總管壁時(shí)縫線(xiàn)針距1.5～2.0 mm，邊距1.0～1.5 mm，2組均在文氏孔處放置腹腔引流管1根。對(duì)照分析2組患者膽總管縫合時(shí)間、手術(shù)時(shí)間、術(shù)中出血量、術(shù)后恢復(fù)情況等指標(biāo)。

2 結(jié) 果

兩組患者均順利完成手術(shù),腹腔引流管于術(shù)后5～6 d拔除,傳統(tǒng)縫線(xiàn)組1例(1.5%)出現(xiàn)手術(shù)并發(fā)癥,為術(shù)后少量膽漏(≤50 mL/d，持續(xù)6 d)，經(jīng)腹腔引流管充分引流后同次住院治愈，倒刺線(xiàn)組無(wú)并發(fā)癥，兩組患者術(shù)后膽瘺發(fā)生率差異無(wú)統(tǒng)計(jì)學(xué)意義(P=0.063)，見(jiàn)表2。術(shù)中出血量(P=0.069)，術(shù)后住院時(shí)間(P=0.083)差異均無(wú)統(tǒng)計(jì)學(xué)意義;膽總管切口縫合時(shí)間(P=0.015)；手術(shù)時(shí)間(P=0.023)，倒刺線(xiàn)組均低于傳統(tǒng)縫線(xiàn)組，差異有統(tǒng)計(jì)學(xué)意義，見(jiàn)表3。術(shù)后每6個(gè)月隨訪(fǎng)復(fù)查B超，2組獲得長(zhǎng)期隨訪(fǎng)(>1年)患者共64例：傳統(tǒng)縫線(xiàn)組52例，倒刺線(xiàn)組12例，均未見(jiàn)殘留結(jié)石及膽管狹窄，無(wú)一例因復(fù)發(fā)結(jié)石或膽管狹窄再次手術(shù)。

表2 兩組患者術(shù)后并發(fā)癥的比較[n(%)]

表3 兩組患者膽管縫合時(shí)間、手術(shù)時(shí)間、術(shù)中出血量及術(shù)后恢復(fù)情況比較

3 討 論

膽總管一期縫合可以避免因放置T管引流所導(dǎo)致的大量膽汁丟失,從而有助于受損肝功能的迅速恢復(fù)。具有恢復(fù)快等優(yōu)點(diǎn)，是一種安全可行的手術(shù)方式。筆者把握的一期縫合的適應(yīng)證為:(1)術(shù)前影像學(xué)檢查已排除肝內(nèi)膽管結(jié)石者;(2)膽總管直徑超過(guò)0.8 cm;(3)術(shù)中探查確定膽總管和肝總管結(jié)石已取凈者;(4)膽總管下端通暢無(wú)狹窄;(5)膽總管黏膜炎癥水腫不嚴(yán)重者[5]。如果膽管直徑較細(xì)(<0.8 cm )，一期縫合膽管狹窄的風(fēng)險(xiǎn)將增加，故放置T管以作支撐更為穩(wěn)妥；腹腔鏡下探查如發(fā)現(xiàn)膽總管炎癥重、膽管壁明顯增厚，考慮到術(shù)后隨著膽管壁炎癥的消退，縫合處張力將降低，膽漏的風(fēng)險(xiǎn)或?qū)⒃黾樱式ㄗh放置T管；膽道鏡下發(fā)現(xiàn)十二指腸乳頭明顯水腫、狹窄、開(kāi)閉功能障礙，膽道壓力較大，亦建議放置T管引流。

腹腔鏡下縫合與打結(jié)是腹腔鏡技術(shù)的難點(diǎn)，是除膽道鏡探查取石外主要決定手術(shù)耗時(shí)的因素。倒刺縫線(xiàn)是一種具有與縫合方向相反的倒刺的單股縫線(xiàn)，由Lacamo于1964年發(fā)明，經(jīng)改進(jìn)后2004年運(yùn)用于臨床[7]。隨著腹腔鏡技術(shù)的發(fā)展，很多新手術(shù)方式的開(kāi)展使腹腔鏡下熟練的縫合、打結(jié)成為縮短手術(shù)時(shí)間的關(guān)鍵因素之一；如何簡(jiǎn)化腔鏡下縫合、打結(jié)技術(shù)，提高縫合可靠性，是目前腹腔鏡發(fā)展的關(guān)注點(diǎn)之一。近些年，倒刺縫線(xiàn)已在腹腔鏡下泌尿外科及胃腸外、婦產(chǎn)科等手術(shù)中得到應(yīng)用[8-13]。與傳統(tǒng)縫線(xiàn)相比，倒刺縫線(xiàn)具有以下優(yōu)勢(shì):(1) 線(xiàn)尾帶一圓環(huán)，縫合第一針后將縫針穿過(guò)圓環(huán)即可收緊，無(wú)需打結(jié)；(2)從第二針起，收緊縫線(xiàn)后既不會(huì)滑脫，一人即可獨(dú)立完成縫合;(3) 縫合結(jié)束時(shí)，剪除多余縫線(xiàn)即可，亦無(wú)需打結(jié)。

在豬作為模型的胃腸道、皮膚切口縫合的試驗(yàn)中，倒刺縫線(xiàn)與傳統(tǒng)縫線(xiàn)對(duì)比研究證實(shí)，倒刺縫線(xiàn)縫合時(shí)間較對(duì)照組縮短約25%，而術(shù)后粘連程度、爆破壓力及組織學(xué)評(píng)分與對(duì)照組相似[14-15]。

倒刺線(xiàn)組病例患者術(shù)后無(wú)膽漏并發(fā)癥發(fā)生，筆者認(rèn)為，在縫合膽總管切口時(shí)注意以下細(xì)節(jié)：(1)倒刺線(xiàn)縫合第一針穿環(huán)時(shí)是沒(méi)有倒刺的，所以在縫合膽總管切口第一針時(shí)在切口上方正常膽管處開(kāi)始縫合，以減少第一針收線(xiàn)不緊導(dǎo)致膽漏的可能；(2)針距保持在1.5～2.0 mm，邊距1.0～1.5 mm;(3)縫合完畢后回縫一針，緊貼組織出針處剪斷縫線(xiàn)，不留殘段。殘留倒刺縫線(xiàn)的尾線(xiàn)可能引起的炎性反應(yīng)或黏連甚至刺入臨近臟器的可能[16]。

本研究證實(shí)在腹腔鏡膽道探查膽總管一期縫合術(shù)中運(yùn)用單向免打結(jié)倒刺縫線(xiàn)縫合膽管是安全可行的，且可以減少手術(shù)時(shí)間，縮短學(xué)習(xí)曲線(xiàn)。

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A comparative study on primary closure of common bile duct using barbed suture after laparoscopic exploration of common bile duct stones

DuanJian,YangShikun，XiaRenping,LinJie,HuangHanfei,XuWanggang，ZengZhong△

(SecondHepatobiliaryDepartment,theFirstAffiliatedHospitalofKunmingMedicalUniversity,Kunming,Yunnan650032,China)

[Abstract] Objective To explore the effectivity and feasibility of uindirectional barbed suture for primary closure of common bile duct on Laparoscopic Exploration of Common Bile Duct Stones.Methods From January 2013 to August 2015,109 cases of primary closure of common bile duct after Laparoscopic Exploration of Common Bile Duct Stones were performed in this hospital.The characteristics of these cases were retrospectively comparatively analyzed.Results Conventional braided Sutures in 68 cases(group A),barbed Suture Devices in 41 cases(group B).There was no difference in postoperative hospital stay,intraoperative blood loss and complication rate between the two groups.Differences in bile duct incision suture time and operative time between the two groups were significantly different.Conclusion The application of uindirectional barbed suture for primary closure of common bile duct using barbed suture after Laparoscopic Exploration is a safe and effective way after treatment of choledocholithiasis.This method cuold reduce the difficulty of operation,and shorten the operation time and the learning curve.

choledocholithiasis;common bile duct;laparoscope;suture

段鍵(1979-)，主治醫(yī)生，碩士，主要從事肝膽外科研究?！?/p>

，E-mail:zzong@medmail.com。

R657.4

A

1671-8348(2017)04-0478-02

2016-09-23

2016-10-21)