目的 探讨医源性胆管损伤的原因、诊治及预防。方法 回顾性分析25例医源性胆管损伤。结果 医源性胆管损伤多发生于胆囊切除术，主要原因有人为因素、胆管解剖变异、局部病理因素等。胆管一旦损伤，如果首次处理不当，则可引发一系列严重并发症。各种类型的胆管损伤应采取不同方法及早处理，对胆漏、腹腔感染较重者先行胆道及腹腔引流术，3个月后再作胆道重建或修复术，手术方法以胆管空肠RouxenY吻合术最为理想。结论 提高医生对胆管损伤的警觉性，术中细致地解剖和规范的操作，是预防医源性胆管损伤的关键。
Objective To discuss the effective surgical treatment of intrahepatic lithiasis combined with high hepatic duct strictures. MethodsTwo hundreds and sixteen cases of intrahepatic lithiasis and high hepatic duct strictures treated in this hospital from January 1993 to October 2002 were analysed retrospectively.ResultsOne hundred and eightythree cases underwent different selective operation by selected time; 33 cases complicated with acute obstructive suppurative cholangitis underwent emergency were performed single biliary drainage, in which 30 cases were reoperated. The operative procedure were: hepatic lobectomy,high cholangiotomy and plastic repair,exposure of hepatic duct of the 2nd and the 3rd order,and plastic repair with own patch and choledochojejunostomy.Two hundreds and six cases were cured,the curative rate was 95.4%; 8 cases improved (3.7%), and 2 cases died (0.9%).Conclusion The best effective surgical treatment of intrahpatic lithiasis is hepatic lobectomy. Exposure of hepatic duct of the 2nd and the 3rd order is a satisfactory to release the hepatic duct strictures and to clear the intrahepatic lithiasis. For patients with normal extrahepatic bile duct and Oddi’s function, plastic repair of bile duct with own patch is possible to keep the normal form and function. Cholangioscopy may play an important role in the treatment of intrahepatic tract lithiasis during operation.
Objective To summarize the experiences in learning laparoscopic cholecystectomy （LC） and discuss young surgeons how to learn LC scientifically. Method The clinical data of 198 patients received LC by myself since I got the qualification of LC were analyzed retrospectively. Results LC was performed successfully in 187 patients with an average operation time of 68 min. Eleven patients were converted to laparotomy. In these 11 patients， 10 patients because of unclear anatomy in Calot triangle and 1 patient because of uncontrollable bleeding due to pathologic anatomy in Calot triangle caused by gallstone. All 198 patients did not suffer from complications such as severe hemorrhage or injury of biliary duct. Liquid therapy and antibiotics therapy were applied in patients with cholecystitis after LC. Food intake and ambulation were recovered at 12-24h after operation. All the patients were discharged from hospital with anaverage of 2.8d after LC. There was no complications related bile duct injury in all of the patients. Conclusion Managed by hierarchical operations management system， mastering regional physiological and variant anatomy， making use of other open cholecystectomy and laparoscopic simulative learning system well， complying with the learning curve， controlling the indications， contraindications and timing of conversion to laparotomy， young surgeons are able to master LC scientifically， safely， and solidly.
Objective To summarize the experiences in diagnosis and treatment for iatrogenic injury of cholodocho-pancreatico-duodenal junction （CPDJ）. Method The clinical data of 9 patients with CPDJ injury were analyzed retro-spectively. Results Double lumen tube drainage was emplaced in all the operations. Nutrition support and inhibitor ofpancreatic secretion were applied in all the patients. ①CPDJ injuries were observed intraoperatively for 6 out of 9 patientswith CPDJ injury. Two patients with simple perforation of posterior wall of common bile duct inferior segment and 2patients with simple duodenal perforation who were treated by perforation repair， common bile duct T tube drainage， andperitoneal drainage. Two cases of bile duct or duodenal injury with pancreatic injury were treated by choledochojejunostomyand BillrothⅡgastrojejunostomy. These 6 patients with CPDJ injury were cured and none of case was death. ②Injuries of CPDJ were observed postoperatively for 3 out of 9 patients with CPDJ injury. Total bile diversion or total bile diversion with duodenal diverticulum were performed in 2 cases of bile duct or duodenal injury with pancreatic injury， respectively. The one with total bile diversion only was died of abdominal infection， duodenal fistula， wound dehiscence， abdominal and upper gastrointestinal tract bleeding， and multiple organ failure；the one with total bile diversion with duodenal diverticulum and the one with sequent PTCD and choledochojejunostomy for biliary obstruction caused by operation ofgigantic duodenal interstitialoma were cured. Conclusions CPDJ injury usually occurs in biliary duct exploration， endoscopic sphincterectomy or duodenal operation. It is easily misdiagnosed and serious consequences may happen from this. Timely and correct treatment should be taken according to the specific injury observed during or after the operation.