Mirizzi综合征的腹腔镜治疗体会
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摘要
本研究是对Mirizzi (Mirizzi Syndrome MS)综合征的术前诊断、应用腹腔镜对该病的治疗方法、手术操作技巧,患者术后恢复情况进行总结分析。结果显示该综合征术前诊断较常见胆道疾病诊断困难,彩超是首选的检查方法,结合ERCP、MRCP等检查能够提高术前诊断率；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,特别是Nagakawa I型是可以在腹腔镜下完成治疗的；对于Ⅲ型及Ⅳ型病人,腹腔镜下处理较为困难,应尽量选择开腹处理。
本文就Mirizzi综合征的手术术式进行分析讨论。不同手术方式各有所长,应严格掌握各自的适应证,在临床治疗中,应以患者的身体状况、临床症状与体征和影像学资料为依据,实施有针对性的手术方式。
Background
Laparoscopic surgery is a minimally invasive technology that make tremendous progress in the field of surgery. A French doctor, Mouret, performed the first case of laparoscopic cholecystectomy in 1987, which created a new era of minimally invasive surgery. Domestic surgeon started to carry out LC from 1991, and then the technology was rapidly popular in our country. It also was used to other domain. The peritoneoscope surgery equipment and the instrument are basically popularized to the county-level hospital by now. But so far the vast majority of the Hospital of domestic carried out small types of laparoscopic surgery. most hospitals is limited to LC. The hospital whose technology develop more quick hospital has been able to apply to general surgery laparoscopic surgery in the other surgery, including appendectomy, hernia repair, gastric plication, colorectal surgery, abdominal exploratory surgery, resection of hepatic hemangioma, liver cyst surgery, improved highly selective vagotomy surgery, adhesion lysis and so on. The peritoneoscope surgery is completely different from the abdomen surgery. It has the specialty of amplification, vision better, from every angle and separation of the organization. causes it operation to be more accurate reliably, which vision better, from every angle and separation of the organization. The peritoneoscope surgery has the advantages of security, less traumatic, scar small, disturbing slightly to the internal organs and rapid postoperative recovery. It has been the general consensus of doctors and patients, and patients generally are willing to accept such a surgery. Moreover, because of small incision laparoscopic surgery, the amount of blood oozing is obviously lower than that of the abdomen surgery, At the same time, the application of the supersonic knife reduces the blood loss obviously when the patients undergo laparoscopic surgery. Because the surgery instrument has small interference of the internal organs, does not destroy the normal physiological dissection structure, avoids holding the abdomen surgery to operate the technique which causes the adhesion, obstruction and so on after the intestinal tract stimulation, all patients after peritoneoscope surgery have less exhaust time, feed time, gets out of bed the active time than the abdomen surgery patients. As the incision shorten recovery time, it significantly reduced risk of wound infection. It obviously reduces application of antibiotics after surgery, avoiding the overuse of antibiotics, which can significantly reduce the complications, such as the flora imbalance, drug resistant, drug adverse reactions, The reduction in hospitalization costs played a role could not be ignored. All the hospital stay was significantly shorter than that of the abdomen surgery patients.
Laparoscopic cholecystectomy has been proven to be the most widely used surgical methods of benign gallbladder disease, the development and the popularization are also most widespread. With the laparoscopic cholecystectomy in surgical extensive application and the continuous improvement of surgical experience, some relative surgical contraindications or absolute contraindications have been gradually expanded indications for surgery. Take Mirizzi syndrome for example, increasing number of surgeons have attention the treatment of it, preoperative, intraoperative and postoperative awareness in laparoscopic operation.
Objective:
To discuss Of the treatment methods and results of laparoscopic in Mirizzi syndrome.
Methods:
From december of 1999 to september of 2009, we retrospectively analyzed of clinical data 26 cases of Mirizzi syndrome patients in department of general surgery, Second hospital of jilin university, to summarize experience of the treat of Mirizzi synthesis under the peritoneoscope.
1. Inclusion criteria:
Preoperative laboratory examinations confirmed or patients with the disease highly considered, as well as intraoperative exploration confirmed the diagnosis of patients.
2. Outcome measures:
Time of onset, whether incarcerated, whether the merger jaundice, extrahepatic bile duct diameter, bilirubin changes, transaminase changes, with or without complications, surgical approach, operative time, postoperative recovery exhaust time, hospitalization time, with or without postoperative disease.
3. Surgical methods:
The surgery were under the general anesthesia to operate completely. We have consummated the correlation inspection before surgery, For the patients existence of complications, we gave the patients and their families an explanation about intraoperative surgical risks and possible scenarios. To combined heart and lung disease patients, we consulted requested relevant departments to assist in treatment. All patients after general anesthesia, routine to establish CO2 pneumoperitoneum (gas abdominal pressure 10-13mmHg).“Three-hole method" or "Four-hole method" was used in conventional surgery. I will slight surgical preoperative preparation and surgical procedure here.
Results:
He average operative time was 145min(range 65min to 325min), average restores exhaust time28h(range 15h to 48h), average in hospital time 11d(range 5d to30d). There were 18 cases of patients were diagnosed type I 14 example success had executed the LC surgery, while four cases relayed to laparotomy.5 cases were diagnosed typeⅡ, of which 2 patients underwent a laparoscopic subtotal cholecystectomy, fistula repair, common bile duct exploration Choledochoscope T drainage pipe. The remaining three cases of abdominal-line transit fistula repair, T tube drainage support.3 cases were diagnosed III type were transit laparotomy, of which 2 patients underwent fistula mouth patching, T tube support drainage. postoperative bile leak, are cured by drainage. There is a routine biliary-enteric anastomosis, postoperative recovery was good.
Conclusion:
1. The diagnose of mirizzi synthesis is difficulty before surgery. Color Doppler ultrasound examination is the preferred method, and ERCP, MRCP can improve the preoperative diagnosis rate.
2. Laparoscopy and laparoscopic bile duct mirror combination can safely handle most type I and type II Mirizzi syndrome cases, in particular, Nagakawa I type can be accomplished in the laparoscopic treatment.
3. For the type III and type IV patients, laparoscopic treatment is more difficult, and we should try to choose abdominal treatment.
本文就Mirizzi综合征的手术术式进行分析讨论。不同手术方式各有所长,应严格掌握各自的适应证,在临床治疗中,应以患者的身体状况、临床症状与体征和影像学资料为依据,实施有针对性的手术方式。
Background
Laparoscopic surgery is a minimally invasive technology that make tremendous progress in the field of surgery. A French doctor, Mouret, performed the first case of laparoscopic cholecystectomy in 1987, which created a new era of minimally invasive surgery. Domestic surgeon started to carry out LC from 1991, and then the technology was rapidly popular in our country. It also was used to other domain. The peritoneoscope surgery equipment and the instrument are basically popularized to the county-level hospital by now. But so far the vast majority of the Hospital of domestic carried out small types of laparoscopic surgery. most hospitals is limited to LC. The hospital whose technology develop more quick hospital has been able to apply to general surgery laparoscopic surgery in the other surgery, including appendectomy, hernia repair, gastric plication, colorectal surgery, abdominal exploratory surgery, resection of hepatic hemangioma, liver cyst surgery, improved highly selective vagotomy surgery, adhesion lysis and so on. The peritoneoscope surgery is completely different from the abdomen surgery. It has the specialty of amplification, vision better, from every angle and separation of the organization. causes it operation to be more accurate reliably, which vision better, from every angle and separation of the organization. The peritoneoscope surgery has the advantages of security, less traumatic, scar small, disturbing slightly to the internal organs and rapid postoperative recovery. It has been the general consensus of doctors and patients, and patients generally are willing to accept such a surgery. Moreover, because of small incision laparoscopic surgery, the amount of blood oozing is obviously lower than that of the abdomen surgery, At the same time, the application of the supersonic knife reduces the blood loss obviously when the patients undergo laparoscopic surgery. Because the surgery instrument has small interference of the internal organs, does not destroy the normal physiological dissection structure, avoids holding the abdomen surgery to operate the technique which causes the adhesion, obstruction and so on after the intestinal tract stimulation, all patients after peritoneoscope surgery have less exhaust time, feed time, gets out of bed the active time than the abdomen surgery patients. As the incision shorten recovery time, it significantly reduced risk of wound infection. It obviously reduces application of antibiotics after surgery, avoiding the overuse of antibiotics, which can significantly reduce the complications, such as the flora imbalance, drug resistant, drug adverse reactions, The reduction in hospitalization costs played a role could not be ignored. All the hospital stay was significantly shorter than that of the abdomen surgery patients.
Laparoscopic cholecystectomy has been proven to be the most widely used surgical methods of benign gallbladder disease, the development and the popularization are also most widespread. With the laparoscopic cholecystectomy in surgical extensive application and the continuous improvement of surgical experience, some relative surgical contraindications or absolute contraindications have been gradually expanded indications for surgery. Take Mirizzi syndrome for example, increasing number of surgeons have attention the treatment of it, preoperative, intraoperative and postoperative awareness in laparoscopic operation.
Objective:
To discuss Of the treatment methods and results of laparoscopic in Mirizzi syndrome.
Methods:
From december of 1999 to september of 2009, we retrospectively analyzed of clinical data 26 cases of Mirizzi syndrome patients in department of general surgery, Second hospital of jilin university, to summarize experience of the treat of Mirizzi synthesis under the peritoneoscope.
1. Inclusion criteria:
Preoperative laboratory examinations confirmed or patients with the disease highly considered, as well as intraoperative exploration confirmed the diagnosis of patients.
2. Outcome measures:
Time of onset, whether incarcerated, whether the merger jaundice, extrahepatic bile duct diameter, bilirubin changes, transaminase changes, with or without complications, surgical approach, operative time, postoperative recovery exhaust time, hospitalization time, with or without postoperative disease.
3. Surgical methods:
The surgery were under the general anesthesia to operate completely. We have consummated the correlation inspection before surgery, For the patients existence of complications, we gave the patients and their families an explanation about intraoperative surgical risks and possible scenarios. To combined heart and lung disease patients, we consulted requested relevant departments to assist in treatment. All patients after general anesthesia, routine to establish CO2 pneumoperitoneum (gas abdominal pressure 10-13mmHg).“Three-hole method" or "Four-hole method" was used in conventional surgery. I will slight surgical preoperative preparation and surgical procedure here.
Results:
He average operative time was 145min(range 65min to 325min), average restores exhaust time28h(range 15h to 48h), average in hospital time 11d(range 5d to30d). There were 18 cases of patients were diagnosed type I 14 example success had executed the LC surgery, while four cases relayed to laparotomy.5 cases were diagnosed typeⅡ, of which 2 patients underwent a laparoscopic subtotal cholecystectomy, fistula repair, common bile duct exploration Choledochoscope T drainage pipe. The remaining three cases of abdominal-line transit fistula repair, T tube drainage support.3 cases were diagnosed III type were transit laparotomy, of which 2 patients underwent fistula mouth patching, T tube support drainage. postoperative bile leak, are cured by drainage. There is a routine biliary-enteric anastomosis, postoperative recovery was good.
Conclusion:
1. The diagnose of mirizzi synthesis is difficulty before surgery. Color Doppler ultrasound examination is the preferred method, and ERCP, MRCP can improve the preoperative diagnosis rate.
2. Laparoscopy and laparoscopic bile duct mirror combination can safely handle most type I and type II Mirizzi syndrome cases, in particular, Nagakawa I type can be accomplished in the laparoscopic treatment.
3. For the type III and type IV patients, laparoscopic treatment is more difficult, and we should try to choose abdominal treatment.
引文
[1]麻伟青,李彦.腹腔镜胆囊切除的麻醉.中华麻醉学杂,994,14：16217.
[2]陈晓东.腹腔镜胆囊切除术中转剖腹的原因分析.肝胆胰外科杂志,999,11：27228.
[3]黄志强.黄志强胆道外科手术学[M].北京：人民军医出版社,993,15-6。
[4]黄志强.必须重视腹腔镜胆囊切除术的安全性.中华外科杂志,995；33：645
[5]Kerin MJ, Gorey TF. Biliary injuries in the laaroscoic era,clinicalreview. Eur J Surg,1994; 160:195
[6]吴水来,等.腹腔镜胆囊切除56例报告.中国内镜杂志,1999；5(1)：37～38
[7]李平,周旭坤,詹辉全.腹腔镜胆囊切除术严重并发症11例教训分析.中国内镜杂志,1999；5(6)：51～52
[8]田新顺,等.腹腔镜胆囊切除术1000例临床分析.中国内镜杂志,2000；6(1)：49～50。
[9]周正东,陈训如,毛静熙,等.腹腔镜胆囊切除术预防肝胆管横 断性损伤的体会.中华外科杂志,1997,5：342～349
[10]邹一平,萧荫祺.腹腔镜胆囊切除术中胆管损伤的防治.中国普通外科杂志,1995；4：310～312
[11]杨建新,徐泽.电视腹腔镜胆囊切除手术难度相关因素分析.中国内镜杂志,1999；5(4)：23～24
[12]杨浩雷,等.腹腔镜胆囊切除术中电凝电切胆囊管及胆囊动脉.中国内镜杂志,1999；5(1)：70
[13]扬锁军卿德科苗建国周建华阎勇蔡忠红田伏洲陈平萍.腹腔镜胆囊切除术中胆囊动脉出血的防范和处理[J]。消化外科2004,3(2)：95-96
[14]唐文杰,李令堂,黎介寿.腹腔镜胆囊切除术技术并发症的预防[J].腹部外科杂志,1995,8(1)：14-15
[15]Duric B, Ignjatovic D, Zivanovic V. New asects in laaroscoic cystic artery anatomy[J]. Acta Chir Iugosl,2000,47(3):105-107
[16]A Haijar N, Duca S, Molnar G, et al. Incidents and ostoerative comlications of laaroscoic cholecystectomies foracute cholecystitis[J]. Rom J Gastroenterol,2002,11 (2):115-119
[17]Glavic Z, Begic L, Rozman R. A new device for the detection and recognition of blood vessels in laaroscoic surgery [J]. Surg Endosc,2002,16(8):1197-1200
[18]Deziel DJ, Mllika KW, Economou SG, et al. Comlicationof laaroscoic cholecystectomy:a national survey of 4292hositals and analysis of 77 604 cases [J]. Am J Surg,1993,165:9-14
[19]Jitea N, Burcos T, Voiculescu S, et al. Analysis of 31 001aaroscoic cholecystectomies [J]. Chirurgia (Bucur),2001,96(6):553-557
[20]李金法.胆囊切除术127例体会[J].肝胆胰外科杂志,1997,9(2)：90
[21]孙经建,石忠凯.胆囊切除后不置引流管更为安全[J].国外医学外科学分册,1991,18(6)：362
[22]杨更光,翟国文,马丽娟,腹腔镜胆囊切除术放置腹腔引流管的临床分析.现代中西医结合杂志,2006,15(21)：2935-2936
[23]刘建,李建设,许元第,等.单纯胆囊切除术中胆总管损伤的防治体会[J].普外临床,1995,10(6)：346-347
[24]陈训如.腹腔镜胆囊切除术临床应用的几个问题[J].普外临床,1993,8(6)：349
[1]Beltran MA, Csendes A. Mirizzi syndrome and gallstone ileus:an unusual presentation of gallstone disease. J Gastrointest Surg 2005;9:686-689
[2]Tan KY, Chng HC, Chen CY, et al. Mirizzi syndrome:noteworthy aspects of a retrospective study in one centre. ANZ J Surg 2004;74:833-837
[3]Gomez G. Mirizzi Syndrome. Curr Treat Options Gastroenterol 2002;5:95-99
[4]Johnson LW, Sehon JK, Lee WC, Zibari GB, McDonald JC. Mirizzi's syndrome:experience from a multi-institutional review. Am Surg 2001;67:11-14
[5]Freeman ME, Rose JL, Forsmark CE, Vauthey J. Mirizzi Syndrome: A rare cause of obstructive jaundice.Dig Dis 1999; 17:44-48
[6]Kelly MD. Mirizzi syndrome. ANZ J Surg 2005;75:501
[7]Rust KR, Clancy TV, Warren G, Mertesdorf J, Maxwell JG. Mirizzi's syndrome:a contraindicationto coelioscopic cholecystectomy. J Laparoendosc Surg 1991;1:133-137
[8]刘新连,陈炜,郭化鑫,等,Mirizzi综合征的诊治分析38例.世界华人消化杂志2005；13：2048-2049
[9]Csendes A, Diaz JC, Burdiles P, Maluenda F, Nava O. Mirizzi syndrome and cholecystobiliary fitula:a unifying classification. Br J Surg 1989;76:1139-1143
[10]Nagakawa T, Ohm T, Kayahara M. A new classification of Mirizzi syndrome f rom diagnostic and therapeutic view2point s[J]. Hepatogast ro enterology,1997,44 (13):63.
[11]Sare M, Gurer S, Taskin B, et al. Mirizzi syndrome:choiceof surgical rocedure in the laaroscoic era [J]. SurgLaarosc Endosc,1998,8:63.
[12]Kok KY. Management of Mirizzi syndrome in the laaroscoic era[J]. Surg Endosc,1998,12(6):1242.
[13]Paul MG, Burris DG, McGuire AM, ThorfinnsonHD, Schonekas H. Laaroscoic surgery in thetreatment of Mirizzi's syndrome. J Laaroendosc Surg 992;2:157-163
[14]Meng WC, Kwok SP, Kelly SB, Lau WY, Li AK. Management of Mirizzi syndrome by laaroscoiccholecystectomy and laaroscoic ultrasonograhy. Br J Surg 1995;82:396
[15]Binnie NR, Nixon SJ, Palmer KR. Mirizzi syndromemanaged by endoscoic stenting and laaroscoiccholecystectomy. Br J Surg 1992;79:647
[16]包毅炎,阍波,朱雯怡,等.结石嵌顿性胆囊炎的腹腔镜手术体会[J].腹腔镜外科杂志,2006,11(5)：439.
[2]陈晓东.腹腔镜胆囊切除术中转剖腹的原因分析.肝胆胰外科杂志,999,11：27228.
[3]黄志强.黄志强胆道外科手术学[M].北京：人民军医出版社,993,15-6。
[4]黄志强.必须重视腹腔镜胆囊切除术的安全性.中华外科杂志,995；33：645
[5]Kerin MJ, Gorey TF. Biliary injuries in the laaroscoic era,clinicalreview. Eur J Surg,1994; 160:195
[6]吴水来,等.腹腔镜胆囊切除56例报告.中国内镜杂志,1999；5(1)：37～38
[7]李平,周旭坤,詹辉全.腹腔镜胆囊切除术严重并发症11例教训分析.中国内镜杂志,1999；5(6)：51～52
[8]田新顺,等.腹腔镜胆囊切除术1000例临床分析.中国内镜杂志,2000；6(1)：49～50。
[9]周正东,陈训如,毛静熙,等.腹腔镜胆囊切除术预防肝胆管横 断性损伤的体会.中华外科杂志,1997,5：342～349
[10]邹一平,萧荫祺.腹腔镜胆囊切除术中胆管损伤的防治.中国普通外科杂志,1995；4：310～312
[11]杨建新,徐泽.电视腹腔镜胆囊切除手术难度相关因素分析.中国内镜杂志,1999；5(4)：23～24
[12]杨浩雷,等.腹腔镜胆囊切除术中电凝电切胆囊管及胆囊动脉.中国内镜杂志,1999；5(1)：70
[13]扬锁军卿德科苗建国周建华阎勇蔡忠红田伏洲陈平萍.腹腔镜胆囊切除术中胆囊动脉出血的防范和处理[J]。消化外科2004,3(2)：95-96
[14]唐文杰,李令堂,黎介寿.腹腔镜胆囊切除术技术并发症的预防[J].腹部外科杂志,1995,8(1)：14-15
[15]Duric B, Ignjatovic D, Zivanovic V. New asects in laaroscoic cystic artery anatomy[J]. Acta Chir Iugosl,2000,47(3):105-107
[16]A Haijar N, Duca S, Molnar G, et al. Incidents and ostoerative comlications of laaroscoic cholecystectomies foracute cholecystitis[J]. Rom J Gastroenterol,2002,11 (2):115-119
[17]Glavic Z, Begic L, Rozman R. A new device for the detection and recognition of blood vessels in laaroscoic surgery [J]. Surg Endosc,2002,16(8):1197-1200
[18]Deziel DJ, Mllika KW, Economou SG, et al. Comlicationof laaroscoic cholecystectomy:a national survey of 4292hositals and analysis of 77 604 cases [J]. Am J Surg,1993,165:9-14
[19]Jitea N, Burcos T, Voiculescu S, et al. Analysis of 31 001aaroscoic cholecystectomies [J]. Chirurgia (Bucur),2001,96(6):553-557
[20]李金法.胆囊切除术127例体会[J].肝胆胰外科杂志,1997,9(2)：90
[21]孙经建,石忠凯.胆囊切除后不置引流管更为安全[J].国外医学外科学分册,1991,18(6)：362
[22]杨更光,翟国文,马丽娟,腹腔镜胆囊切除术放置腹腔引流管的临床分析.现代中西医结合杂志,2006,15(21)：2935-2936
[23]刘建,李建设,许元第,等.单纯胆囊切除术中胆总管损伤的防治体会[J].普外临床,1995,10(6)：346-347
[24]陈训如.腹腔镜胆囊切除术临床应用的几个问题[J].普外临床,1993,8(6)：349
[1]Beltran MA, Csendes A. Mirizzi syndrome and gallstone ileus:an unusual presentation of gallstone disease. J Gastrointest Surg 2005;9:686-689
[2]Tan KY, Chng HC, Chen CY, et al. Mirizzi syndrome:noteworthy aspects of a retrospective study in one centre. ANZ J Surg 2004;74:833-837
[3]Gomez G. Mirizzi Syndrome. Curr Treat Options Gastroenterol 2002;5:95-99
[4]Johnson LW, Sehon JK, Lee WC, Zibari GB, McDonald JC. Mirizzi's syndrome:experience from a multi-institutional review. Am Surg 2001;67:11-14
[5]Freeman ME, Rose JL, Forsmark CE, Vauthey J. Mirizzi Syndrome: A rare cause of obstructive jaundice.Dig Dis 1999; 17:44-48
[6]Kelly MD. Mirizzi syndrome. ANZ J Surg 2005;75:501
[7]Rust KR, Clancy TV, Warren G, Mertesdorf J, Maxwell JG. Mirizzi's syndrome:a contraindicationto coelioscopic cholecystectomy. J Laparoendosc Surg 1991;1:133-137
[8]刘新连,陈炜,郭化鑫,等,Mirizzi综合征的诊治分析38例.世界华人消化杂志2005；13：2048-2049
[9]Csendes A, Diaz JC, Burdiles P, Maluenda F, Nava O. Mirizzi syndrome and cholecystobiliary fitula:a unifying classification. Br J Surg 1989;76:1139-1143
[10]Nagakawa T, Ohm T, Kayahara M. A new classification of Mirizzi syndrome f rom diagnostic and therapeutic view2point s[J]. Hepatogast ro enterology,1997,44 (13):63.
[11]Sare M, Gurer S, Taskin B, et al. Mirizzi syndrome:choiceof surgical rocedure in the laaroscoic era [J]. SurgLaarosc Endosc,1998,8:63.
[12]Kok KY. Management of Mirizzi syndrome in the laaroscoic era[J]. Surg Endosc,1998,12(6):1242.
[13]Paul MG, Burris DG, McGuire AM, ThorfinnsonHD, Schonekas H. Laaroscoic surgery in thetreatment of Mirizzi's syndrome. J Laaroendosc Surg 992;2:157-163
[14]Meng WC, Kwok SP, Kelly SB, Lau WY, Li AK. Management of Mirizzi syndrome by laaroscoiccholecystectomy and laaroscoic ultrasonograhy. Br J Surg 1995;82:396
[15]Binnie NR, Nixon SJ, Palmer KR. Mirizzi syndromemanaged by endoscoic stenting and laaroscoiccholecystectomy. Br J Surg 1992;79:647
[16]包毅炎,阍波,朱雯怡,等.结石嵌顿性胆囊炎的腹腔镜手术体会[J].腹腔镜外科杂志,2006,11(5)：439.