Name: laparoscopic common bile duct exploration in patients with a previous history of biliary tract surgery
Uploaded: 2023-02-10T13:43:00
Description: Watch this Scientific Journal Video about Laparoscopic Common Bile Duct Exploration in Patients with a Previous History of Biliary Tract Surgery at JoVE.com

这项工作得到了广东省医学科学研究基金（编号：A2021091）、中央高校基础研究费专项（编号21622312）、广州市基础研究计划基础与应用基础研究项目（编号：2023A04J01111）、暨南大学附属第一医院普外科旗舰专科建设项目（编号：711003）的资助。 暨南大学附属顺德医院科研发展专项基金（202101004号）。

共纳入177例在2010年9月至2021年12月期间接受LCBDE的有胆道手术史的患者。本研究获得暨南大学附属第一医院机构评审委员会的批准。所有患者均提供了书面知情同意书。
1. 入选标准
<ol><li>包括胆总管 （CBD） 中有两个以上结石的患者。</li>
	<li>包括总直径为 ≥20 毫米的 CBD 结石患者。</li>
	<li>包括 CBD 直径为 ≥10 毫米的患者。</li>
</ol>2. 排除?...

<ol>
	<li>Kim, Y. J., Chung, W. C., Jo, I. H., Kim, J., Kim, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Efficacy+of+endoscopic+ultrasound+after+removal+of+common+bile+duct+stone.">Efficacy of endoscopic ultrasound after removal of common bile duct stone.</a> Scandinavian Journal of Gastroenterology. 54 (9), 1160-1165 (2019).</li><li>Poh, B. R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Randomized+clinical+trial+of+intraoperative+endoscopic+retrograde+cholangiopancreatography+versus+laparoscopic+bile+duct+exploration+in+patients+with+choledocholithiasis.">Randomized clinical trial of intraoperative endoscopic retrograde cholangiopancreatography versus laparoscopic bile duct exploration in patients with choledocholithiasis.</a> The British Journal of Surgery. 103 (9), 1117-1124 (2016).</li><li>Bansal, V. K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Single-stage+laparoscopic+common+bile+duct+exploration+and+cholecystectomy+versus+two-stage+endoscopic+stone+extraction+followed+by+laparoscopic+cholecystectomy+for+patients+with+concomitant+gallbladder+stones+and+common+bile+duct+stones:+a+randomized+controlled+trial.">Single-stage laparoscopic common bile duct exploration and cholecystectomy versus two-stage endoscopic stone extraction followed by laparoscopic cholecystectomy for patients with concomitant gallbladder stones and common bile duct stones: a randomized controlled trial.</a> Surgical Endoscopy. 28 (3), 875-885 (2014).</li><li>Wang, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+surgery+for+choledocholithiasis+concomitant+with+calculus+of+the+left+intrahepatic+duct+or+abdominal+adhesions.">Laparoscopic surgery for choledocholithiasis concomitant with calculus of the left intrahepatic duct or abdominal adhesions.</a> Surgical Endoscopy. 31 (11), 4780-4789 (2017).</li><li>Aawsaj, Y., Light, D., Horgan, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+common+bile+duct+exploration:+15-year+experience+in+a+district+general+hospital.">Laparoscopic common bile duct exploration: 15-year experience in a district general hospital.</a> Surgical Endoscopy. 30 (6), 2563-2566 (2016).</li><li>Li, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+common+bile+duct+exploration+in+patients+with+previous+abdominal+biliary+tract+operations.">Laparoscopic common bile duct exploration in patients with previous abdominal biliary tract operations.</a> Surgical Endoscopy. 34 (4), 1551-1560 (2020).</li><li>Li, Q., Chen, L., Liu, S., Chen, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+of+laparoscopic+common+bile+duct+exploration+with+endoscopic+retrograde+cholangiopancreatography+for+common+bile+duct+stones+after+cholecystectomy.">Comparison of laparoscopic common bile duct exploration with endoscopic retrograde cholangiopancreatography for common bile duct stones after cholecystectomy.</a> Journal of Laparoendoscopic &amp; Advanced Surgical Techniques. Part A. 32 (9), 992-998 (2022).</li><li>Zhu, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+common+bile+duct+exploration+for+patients+with+a+history+of+prior+biliary+surgery:+a+comparative+study+with+an+open+approach.">Laparoscopic common bile duct exploration for patients with a history of prior biliary surgery: a comparative study with an open approach.</a> ANZ Journal of Surgery. 91 (3), E98-E103 (2021).</li><li>Singh, K., Ohri, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Anatomic+landmarks:+their+usefulness+in+safe+laparoscopic+cholecystectomy.">Anatomic landmarks: their usefulness in safe laparoscopic cholecystectomy.</a> Surgical Endoscopy. 20 (11), 1754-1758 (2006).</li><li>Liang, J., Ye, W., Li, J., Cao, M., Hu, Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+applied+anatomy+in+trans-areolar+endoscopic+thyroidectomy:+crucial+anatomical+landmarks.">Clinical applied anatomy in trans-areolar endoscopic thyroidectomy: crucial anatomical landmarks.</a> Journal of Laparoendoscopic &amp; Advanced Surgical Techniques. Part A. 30 (7), 803-809 (2020).</li><li>Jain, N., Srivastava, S., Bayya, S. L. P., Jain, V. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Jain+point+laparoscopic+entry+in+contraindications+of+Palmers+point.">Jain point laparoscopic entry in contraindications of Palmers point.</a> Frontiers in Surgery. 9, 928081 (2022).</li><li>Gui, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+common+bile+duct+exploration+versus+open+approach+in+cirrhotic+patients+with+choledocholithiasis:+a+retrospective+study.">Laparoscopic common bile duct exploration versus open approach in cirrhotic patients with choledocholithiasis: a retrospective study.</a> Journal of Laparoendoscopic &amp; Advanced Surgical Techniques. Part A. 26 (12), 972-977 (2016).</li><li>Xia, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+strategy+for+recurrent+common+bile+duct+stones:+a+10-year+experience+of+a+single+center.">Surgical strategy for recurrent common bile duct stones: a 10-year experience of a single center.</a> Updates in Surgery. 73 (4), 1399-1406 (2021).</li><li>Phillips, E. H., Carroll, B. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=New+techniques+for+the+treatment+of+common+bile+duct+calculi+encountered+during+laparoscopic+cholecystectomy.">New techniques for the treatment of common bile duct calculi encountered during laparoscopic cholecystectomy.</a> Problems in General Surgery. 8 (3), 387-394 (1991).</li><li>Alkhamesi, N. A., Davies, W. T., Pinto, R. F., Schlachta, C. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robot-assisted+common+bile+duct+exploration+as+an+option+for+complex+choledocholithiasis.">Robot-assisted common bile duct exploration as an option for complex choledocholithiasis.</a> Surgical Endoscopy. 27 (1), 263-266 (2013).</li><li>Ye, C., Zhou, W., Zhang, H., Miao, L., Lv, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Alterations+of+the+bile+microbiome+in+recurrent+common+bile+duct+stone.">Alterations of the bile microbiome in recurrent common bile duct stone.</a> BioMed Research International. 2020, 4637560 (2020).</li><li>Goong, H. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+role+of+endoscopic+biliary+drainage+without+sphincterotomy+in+gallstone+patients+with+cholangitis+and+suspected+common+bile+duct+stones+not+detected+by+cholangiogram+or+intraductal+ultrasonography.">The role of endoscopic biliary drainage without sphincterotomy in gallstone patients with cholangitis and suspected common bile duct stones not detected by cholangiogram or intraductal ultrasonography.</a> Gut and Liver. 11 (3), 434-439 (2017).</li><li>Zhen, W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Primary+closure+versus+T-tube+drainage+following+laparoscopic+common+bile+duct+exploration+in+patients+with+previous+biliary+surgery.">Primary closure versus T-tube drainage following laparoscopic common bile duct exploration in patients with previous biliary surgery.</a> The American Surgeon. 87 (1), 50-55 (2021).</li><li>Zhang, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Primary+closure+following+laparoscopic+common+bile+duct+reexploration+for+the+patients+who+underwent+prior+biliary+operation.">Primary closure following laparoscopic common bile duct reexploration for the patients who underwent prior biliary operation.</a> The Indian Journal of Surgery. 78 (5), 364-370 (2016).</li><li>Wang, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Efficacy+and+safety+of+laparoscopic+common+bile+duct+exploration+via+choledochotomy+with+primary+closure+for+the+management+of+acute+cholangitis+caused+by+common+bile+duct+stones.">Efficacy and safety of laparoscopic common bile duct exploration via choledochotomy with primary closure for the management of acute cholangitis caused by common bile duct stones.</a> Surgical Endoscopy. 36 (7), 4869-4877 (2022).</li><li>Zhu, T., Lin, H., Sun, J., Liu, C., Zhang, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Primary+duct+closure+versus+T-tube+drainage+after+laparoscopic+common+bile+duct+exploration:+a+meta-analysis.">Primary duct closure versus T-tube drainage after laparoscopic common bile duct exploration: a meta-analysis.</a> Journal of Zhejiang University. Science. B. 22 (12), 985-1001 (2021).</li></ol>

胆总管结石最常见的原因是结石通过胆囊落入 CBD，而一些 CBD 结石可能来自 CBD 本身1。胆总管结石患者胆总管结石的发生率为10%-18%，4%-24%的胆总管结石患者在第一次截石术后复发，常需重复手术12，13。自1991年LCBDE首次应用以来，它已被证明对治疗胆总管结石是安全有效的，并且由于手术可以在一个阶段完成，因此得到了广泛的接受和...

胆总管结石是最常见的胆道疾病之一，复发率高1。由于复发性胆总管结石通常涉及多块结石，再加上内镜逆行胰胆管造影术 （ERCP）/内镜括约肌切开术 （EST） 可能会损害 Oddi 括约肌的功能并导致反复逆行胆道感染，因此复发性胆总管结石患者通常需要两次或两次以上的外科手术2。
随着微创手术的普及和腹腔镜技术的进步，腹腔镜胆总管探查术（LCBDE）凭借创伤小、恢复快、保留Oddi括约肌功能等优点，在临床上得到了广泛的应用。复发性胆总管结石患者的腹部粘连导致解剖结构改变，因此这些患者在随后的胆管探查中容易发生继发性损伤。因此，腹腔粘连被认为是腹腔镜手术的禁忌症4，5。随着技术的进一步发展，LCBDE已被初步证实在有胆道手术史的患者中是可行的6，7，8。
然而，相关研究有限，仍需要对这种手术技术进行更深入的研究。LCBDE的编程操作通常缺乏，特别是对于有广泛腹部粘连的患者。基于这种情况，本研究旨在通过调查LCBDE在有胆道手术史的患者中的手术方法和解剖标志来开发一种程序化程序。基于手术方法和解剖标志的程序化手术可以帮助缩短手术时间，减少并发症并提高手术安全性9，10。

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Electronic choledochoscope</td>
			<td>Olympus</td>
			<td>CHF-V</td>
			<td>/</td>
		</tr>
		<tr>
			<td>Harmonic scalpel</td>
			<td>Ethcion</td>
			<td>HAR36</td>
			<td>/</td>
		</tr>
		<tr>
			<td>Stone basket</td>
			<td>Cook</td>
			<td>NTSE-045065-UDH</td>
			<td>/</td>
		</tr>
	</tbody>
</table>

laparoscopic common bile duct exploration in patients with a previous history of biliary tract surgery

对于复发性胆总管结石，既往手术中的腹部粘连会导致解剖结构发生变化，并且在进行腹腔镜胆总管探查（LCBDE）的另一次手术时容易发生继发性损伤，这曾经被认为是相对禁忌症。鉴于目前手术技术的局限性，本研究总结了LCBDE再次手术的手术方法和关键解剖标志。提出了4种普通外科方法暴露胆总管，包括黄皮韧带入路、肝十二指肠前韧带入路、右肝十二指肠韧带入路和混合入路。此外，这项研究还强调了七个关键的解剖标志：顶腹膜、胃肠道浆膜、肝韧带、肝下缘、胃窦、十二指肠和结肠肝弯曲，有助于安全地分离腹膜粘连并暴露胆总管。此外，为了缩短胆总管取石术的时间，创新性地采用顺序方法去除胆总管结石。掌握上述手术方法，包括识别关键解剖标志和采用序贯法，将提高LCBDE再次手术的安全性，缩短手术时间，促进患者快速康复，减少术后并发症，有助于该技术的推广应用。

这项研究包括177名患者（平均年龄：61.74±5.97岁），包括79名男性和98名女性。共有69例患者有开放性胆囊切除术（OC）病史;36例患者有OC和开放性胆总管探查（OCBDE）病史;8例患者有OC、OCBDE和左叶肝切除术（LLH）病史;3例患者有OC、OCBDE和胆总管空肠吻合术史;42例患者有腹腔镜胆囊切除术（LC）病史;7例患者有LC和LCBDE病史;12例患者有LC和OCBDE病史（表1）。
共有174例患者...

Watch this Scientific Journal Video about Laparoscopic Common Bile Duct Exploration in Patients with a Previous History of Biliary Tract Surgery at JoVE.com

Laparoscopic Common Bile Duct Exploration in Patients with a Previous History of Biliary Tract Surgery

基于手术方法和解剖标志物的程序化手术有助于缩短手术时间，减少并发症，并提高手术的安全性。本研究对有胆道手术史的患者腹腔镜胆总管探查的手术方法及解剖标志物进行了调查和总结。

有胆道手术史患者的腹腔镜胆总管探查

For recurrent choledocholithiasis, abdominal adhesions in previous surgeries lead to changes in anatomical structures, and a secondary injury occurs ...

该协议旨在通过调查有胆道手术史的患者腹腔镜胆总管探查（LCBDE）的手术方法和解剖标志来开发程序。基于手术方法和解剖标志的程序化手术可以帮助缩短手术时间，减少并发症，提高手术安全性，并进一步促进该技术的应用。在肝圆韧带入路中，分离并释放沿肝圆韧带到下肝缘的腹粘连，然后到肝氦以暴露胆总管或CBD。在肝十二指肠前韧带入路中，将十二指肠与肝门向下分开，使 CBD 暴露在肝十二指肠韧带的前部。在右肝十二指肠韧带入路中，分离粘附在肝门上的结肠的肝弯曲，从肝十二指肠韧带的右侧侧向下，露出右肝下间隙和网膜孔之间的区域，从而确定CBD的位置。在混合方法中，结合两种或三种已证明的方法，这主要取决于粘附的位置。如果前腹壁中间有粘连，请使用肝圆韧带入路。如果CBD的前部和两侧存在粘连，请使用前肝十二指肠韧带方法。如果右上腹部有粘连，请使用右肝十二指肠韧带入路。如果腹腔内有广泛的粘连，请使用混合方法。灵活交替地使用这三种方法，从近到远，从简单到复杂，从松散组织到粘附和致密组织开始分离。识别顶腹膜和胃肠道肝硬化。使用无创抓钳夹住和拉动胃肠道，以适当的牵引张力粘附在腹壁上。然后，分离并释放靠近壁腹膜和胃肠道肝硬化的粘连。用钝性解剖或超声波手术刀分离松散的粘连。然后，用剪刀释放致密的粘连或涉及肠道的粘连，以避免热损伤。接下来，确定肝圆韧带标志。在有胆道手术史的患者中，胃窦、十二指肠、肝和腹壁之间通常存在相互粘连。通过沿肝圆韧带向上分离粘连并暴露胃窦和十二指肠来找到下肝缘。通过肝圆韧带暴露下肝缘后，沿肝脏内脏表面向下分离粘连，进一步暴露胃窦和十二指肠。如果损伤不可避免，应根据损伤肝脏而不是胃肠道的原则，将靠近肝脏的粘连分开。胃窦和十二指肠的第一和第二节倾向于向上移动并通过粘连封住第一肝门区域。将沿肝脏内脏表面向下的粘连与下肝缘分开，并暴露胃窦和十二指肠。然后，降低胃窦和十二指肠以进一步暴露 CBD。通过识别结肠的肝弯曲来暴露CBD，分离右上腹部网膜，肠和腹壁之间的粘连，并找到结肠的肝弯曲。将结肠的肝弯曲与右下肝缘分开并降低。通过将粘连从右侧肝下空间分离到网膜孔来暴露 CBD。要用镊子进行腹腔镜截石术，请使用无创抓钳推动CBD的下段，并将大结石挤压到CBD的切口。用镊子直接取出结石。要通过盲篮提取进行腹腔镜截石术，请将石篮插入 CBD 并打开它。然后，在没有结肠镜协助的情况下反复上下拉篮子。通过盲篮提取去除无法挤压到CBD切口的结石，这大大缩短了结肠镜截石术的时间。要通过用盐水冲洗 CBD 来去除结石，请将硅胶管插入 CBD。使用50毫升注射器通过硅胶管将盐水注入CBD，并冲洗掉小结石。要进行结肠镜截石术，请将结肠镜插入CBD，并通过结肠镜冲洗通道连续注入盐水。通过结肠镜的仪器通道将取石篮放入CBD。打开篮子，然后在结肠镜的直接视野下取出结石。共有174例患者成功接受了CBD探查，3例患者因CBD壁术中出血转为剖腹手术。平均手术时间约为163.72分钟。术中平均失血量约为87.51毫升。到第一次肠胃气胀的时间是28.94小时。术后平均引流量约为196.27毫升。住院时间为6.93天。术后并发症发生率9.0%术后胆漏3例，术后出血1例，残余结石5例，腹部感染1例，切口感染6例。为了获得成功的手术结果，在根据解剖标志进行粘附分离和CBD暴露时要格外小心，这一点至关重要。

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Neointimal hyperplasia is one the primary causes of stenosis in arterialized veins that are of great importance in arterial coronary bypass surgery, in ...

3-Dimensional Resin Casting and Imaging of Mouse Portal Vein or Intrahepatic Bile Duct System

树脂浇铸和3维成像的小鼠门静脉或肝内胆管系统

In  organs, the correct architecture of vascular and ductal structures is  indispensable for proper physiological function, and the formation and  ...

Surgical Procedures for a Rat Model of Partial Orthotopic Liver Transplantation with Hepatic Arterial Reconstruction

部分原位肝移植大鼠模型的肝动脉重建的外科手术

Orthotopic liver transplantation (OLT) in rats using a whole or partial graft is an indispensable experimental model for transplantation research, such as ...

Computerized Dynamic Posturography for Postural Control Assessment in Patients with Intermittent Claudication

Computerized dynamic posturography with the EquiTest is an objective technique for measuring postural strategies under challenging static and dynamic ...

Bile Duct Ligation in Mice: Induction of Inflammatory Liver Injury and Fibrosis by Obstructive Cholestasis

胆管结扎小鼠：感应炎性肝损伤和纤维化的阻塞性胆汁淤积

In most vertebrates, the liver produces bile that is necessary to emulsify absorbed fats and enable the digestion of lipids in the small intestine as well ...

Intraoperative Gastroscopy for Tumor Localization in Laparoscopic Surgery for Gastric Adenocarcinoma

胃镜检查术在腹腔镜手术的肿瘤定位于胃腺癌

Determining resection margins for gastric cancer, which are not exposed to the serosal surface of the stomach, is the most important procedure during ...

A Quantitative Sensory Testing Paradigm to Obtain Measures of Pain Processing in Patients Undergoing Breast Cancer Surgery

一种定量感官检测方法在乳腺癌手术患者疼痛处理中的研究

Chronic pain following surgery, persistent postsurgical pain, is an important highly prevalent condition contributing to significant symptom burden and ...

A Mouse Model for Chronic Pancreatitis via Bile Duct TNBS Infusion

通过胆管 TNBS 输液治疗慢性胰腺炎的鼠标模型

Chronic pancreatitis (CP) is a complex disease involving pancreatic inflammation and fibrosis, glandular atrophy, abdominal pain and other symptoms. ...