探讨腹腔镜超声在腹腔镜肝切除术治疗肝胆管结石中的临床应用价值。

回顾性分析2014年3月至2016年2月川北医学院附属医院行腹腔镜肝切除术的48例肝胆管结石患者临床资料。患者均签署知情同意书，符合医学伦理学规定。其中男17例，女29例；年龄36～76岁，中位年龄56岁。术中采用腹腔镜超声明确结石的位置、范围、胆管狭窄的部位，肝内重要血管及胆管的走行情况，通过超声实时引导肝实质切除，并应用胆道镜对剩余肝叶或肝段内胆管、肝外胆管进行探查、取石。

46例成功施行腹腔镜肝切除术，2例分别因腹腔致密粘连、肝门胆管狭窄而中转开腹。术中腹腔镜超声探查发现术前结石诊断不明确5例，区分肝内钙化4例。超声定位取石2例。23例半肝切除均借助术中超声显示肝中静脉走行，仅1例发生肝中静脉损伤。患者平均手术时间（308±146）min，术中出血量（460±280）ml。无围手术期死亡，术后并发症7例，其中肝断面积液伴感染2例，胸腔积液3例，肺部感染1例，切口感染1例。残留结石4例，术后8周经T管窦道完全取出。术后住院时间（14±7）d。随访期间肝内结石复发3例。

肝胆管结石腹腔镜肝切除术中借助腹腔镜超声有助于明确结石的位置、范围、胆管狭窄的部位、肝中静脉等重要血管的走行情况，帮助制定合理的手术规划，可降低结石残留及复发率，提高手术的安全性、精准性。

To evaluate the clinical application value of laparoscopic ultrasonography in laparoscopic hepatectomy in the treatment of hepatolithiasis.

Clinical data of 48 patients with hepatolithiasis undergoing laparoscopic hepatectomy in the Affiliated Hospital of North Sichuan Medical College from March 2014 to February 2016 were retrospectively analyzed. The informed consents of all patients were obtained and the local ethical committee approval was received. 17 patients were males and 29 females, aged 36-76 years with a median of 56 years. The location and range of stones, bile duct stenosis and distribution of intrahepatic vessels and bile ducts were observed by laparoscopic ultrasonography. Liver resection was performed with the guidance of real-time ultrasound. And choledochoscope was used for the exploration and removal of stones in the remaining liver or intra- and extrahepatic bile ducts.

A totalof 46 patients underwent laparoscopic hepatectomy successfully, 2 cases were converted to laparotomy due to severe abdominal adhesion and hilar bile duct stenosis. Laparoscopic ultrasound-assisted exploration found that 5 cases were with unclear preoperative diagnosis of hepatolithiasis, 4 with differentiated intrahepatic calcification. 2 cases received ultrasound-located removal of stones. The distribution of middle hepatic veins were displayed by intraoperative ultrasound in 23 patients undergoing partial hepatectomy, and hepatic vein injury occurred in 1 case. The mean operation time was (308±146) min, and the intraoperative blood loss was (460±280) ml. No death was observed during the perioperative period. Postoperative complications occurred in 7 cases, including 2 cases of hepatic effusion complicated with infection at the resected liver surface, 3 cases of pleural effusion, 1 case of pulmonary infection, and 1 case of incision infection. Residual stones were found in 4 cases, which were removed completely through T-tube sinus tract at postoperative 8 weeks. Postoperative length of hospital stay was (14±7) d. Hepatolithiasis recurred in 3 cases during the follow-up.

Laparoscopic ultrasonography can be used in laparoscopic hepatectomy for hepatolithiasis to determine the location and range of stones, location of bile duct stenosis, and the distribution of important vessels, such as middle hepatic vein, so as to make a reasonable surgical plan. It can help to reduce the residual stones, the recurrence rate, and to increase the safety and precision of surgery.