探讨腹腔镜联合胆道镜再次胆总管探查在肝内外胆管结石患者中的应用价值。

回顾性分析2014年6月至2016年5月复旦大学附属中山医院收治的79例既往有胆道手术史的肝内外胆管结石患者临床资料。按照治疗方法将患者分成腹腔镜联合胆道镜组（双镜联合组）和开腹组。其中双镜联合组43例，男18例，女25例；平均年龄（63±14）岁。开腹组36例，男19例，女17例；年龄（63±12）岁。患者均签署知情同意书，符合医学伦理学规定。两组手术时间、住院费用比较采用t检验，术中出血量、术后胃肠道恢复时间、术后住院时间比较采用Z检验，并发症发生率比较采用χ²检验或Fisher确切概率法。

双镜联合组患者手术时间为（5.2±1.8）h，明显长于开腹组的（2.4±1.3）h（t=7.371，P<0.05）。双镜联合组的术中出血量中位数为30（5～200）ml，与开腹组的40（10～400）ml比较差异无统计学意义（Z=-0.270，P>0.05）。双镜联合组患者的术后胃肠道恢复时间、术后住院时间分别为3（1～9）、8（3～18）d，开腹组相应为3（1～29）、9（2～97）d，差异无统计学意义（Z=-1.475，-2.023；P>0.05）。双镜联合组患者的住院费用3.4 （0.7～9.6）万元，明显高于开腹组的2.8（1.4～9.6）万元（Z=2.495，P<0.05）。双镜联合组术后结石残余率、胆漏发生率、切口感染发生率分别为12%（5/43）、0、0，开腹组相应为19%（7/36）、6%（2/36）、3%（1/36），差异无统计学意义（P>0.05）。

腹腔镜联合胆道镜双镜治疗既往有腹部胆道手术史的肝内外胆管结石是一种安全、有效的手术方式。

To explore the application value of common bile duct re-exploration under laparoscope combined with choledochoscope in patients with intra- and extrahepatic bile duct stone.

Clinical data of 79 patients with intra- and extrahepatic bile duct stone who had previous operative history of biliary tract in Zhongshan Hospital Affiliated to Fudan Univesity between June 2014 and May 2016 were retrospectively analyzed. According to the treatment method, the patients were divided into the laparoscope combined with choledochoscope group (two-scope group) and laparotomy group. There were 43 cases in two-scope group, including 18 males and 25 females with the average age of (63±14) years. There were 36 cases in laparotomy group, including 19 males and 17 females with the age of (63±12) years. The informed consents of all patients were obtained and the local ethical committee approval was received. The operation time and hospitalization expenses of two groups were compared by t test. The intraoperative blood loss, postoperative recovery time of gastrointestinal tract were compared by Z test. The incidence of complications was compared by Chi-square test or Fisher's exact probability method.

The operation time of patients in two-scope group was (5.2±1.8) h, significantly longer than (2.4±1.3) h of the laparotomy group (t=7.371, P<0.05). The median of intraoperative blood loss in two-scope group was 30(5-200) ml and was 40(10-400) ml in laparotomy group, and no significant difference was observed (Z=-0.270, P>0.05). The postoperative recovery time of gastrointestinal tract and postoperative hospitalization time in two-scope group was 3(1-9) and 8(3-18) d respectively, and was 3(1-29) and 9(2-97) d in laparotomy group, and no significant difference was observed (Z=-1.475, -2.023; P>0.05). The hospitalization expenses of the two-scope group was 34(7-96) thousand yuan, significantly more than 28(14-96) thousand yuan of the laparotomy group (Z=2.495, P<0.05). The postoperative residual rate of stone, incidence of bile leakage and incision infection of the two-scope group was respectively 12%(5/43), 0 and 0, and was 19%(7/36), 6%(2/36) and 3%(1/36) in laparotomy group, and no significant difference was observed (P>0.05).

Laparoscope combined with choledochoscope is a safe and effective operation for intra- and extrahepatic bile duct stone with previous operative history of biliary tract.