Mirizzi综合征诊断及腹腔镜治疗临床分析.docVIP

Mirizzi综合征诊断及腹腔镜治疗临床分析 　【摘要】 目的：探讨Mirizzi综合征的诊断及腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）治疗Mirizzi综合征的价值及术中处理方法。方法：回顾分析1996年5月至2006年10月3 651例LC术中37例Mirizzi综合征患者的临床资料。结果：37例中Ⅰ型30例，28例成功施行了LC或大部切除术，2例中转开腹；Ⅱ型5例，3例施行了腹腔镜胆囊大部切除，瘘口修补，胆总管切开胆道镜探查T管支撑引流术，2例中转开腹；Ⅲ型2例均中转开腹。术后发生胆漏3例均经引流痊愈。结论：B超是首选的检查方法，ERCP、MRCP能提高术前诊断率。腹腔镜及腹腔镜胆道镜联合应用能安全处理大部分Ⅰ型和Ⅱ型的Mirizzi综合征病例。 【关键词】 Mirizzi综合征；诊断；胆囊切除术，腹腔镜 【Abstract】 Ｏbjective:To evaluate the value of laparoscopic cholecystectomy (LC) and perioperative treatment for Mirizzi syndrome.Methods:Three thousand six hundred and fiftyone cases were performed LC from 1996 to 2006 in our hospital,and the clinical data of 37 cases with Mirizzi syndrome was analysis retrospectively.Results:There were 30 cases of type Ⅰ，5 cases of type Ⅱ,2 cases of type Ⅲ.28 cases of type Ⅰ were performed with LC or laparoscopic subtotal cholecystectomy successfully,3 cases of type Ⅱwere performed with laparoscopic subtotal cholecystectomy,repair of fistula,cholangiscopic exploration plus T tube placement drainage,2 cases of three types were converted to open laparotomy separately,3 cases with postoperative biliary leak were cured by drainage.Conclusions:BUS is the first choice of examination,MRCP and ERCP can improve the preoperative diagnostic rate.Laparoscopy plus cholangiscopy are effective and safe for type Ⅰ,type Ⅱ cases with Mirizzi syndrome. 【Key words】 Mirizzi syndrome;Diagnosis;Cholecystectomy,laparoscopic Mirizzi综合征是胆囊颈或胆囊管结石嵌顿及其炎症所引起的胆总管梗阻，是慢性胆囊炎、胆囊结石的少见并发症，其发生率占同期胆囊切除的1.0%～2.7%［1］。在开腹，尤其是腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)中往往因术前不能明确诊断，增加了医源性胆道损伤的风险［2］，是胆道外科中较为棘手的问题。 1996年5月至2006年10月我院共完成3 651例LC，其中Mirizzi综合征37例。现就本组病例诊断治疗的经过与结果报道如下。 1 资料与方法 1.1 临床资料 本组37例中男14例，女23例。30～78岁，平均46.3岁。其中反复发作上腹痛33例，有黄疸史29例，发热9例，18例可扪及肿大胆囊。血生化提示直接胆红素升高27例，碱性磷酸酶、γ谷胺酰转移酶升高30例，白细胞升高8例。B超检查提示胆囊颈、胆囊管结石嵌顿28例（75.7%)，胆囊肿大26例，胆囊萎缩8例，肝内胆管扩张31例，均未见肝内胆管结石。7例行ERCP检查，其中发现胆总管偏侧性狭窄5例；8例行MRCP检查，显示胆总管偏侧性狭窄5例，并同时显示胆囊及胆囊颈结石。但影像学检查均未显示跨行于胆囊管与胆总管之间的结石。 1.2 手术方法 均采用四孔法,将胆囊管提起,若见壶腹部、胆囊颈、胆囊管结石