探讨腹腔镜肝切除术在肝胆管结石分型治疗中的策略及疗效。

回顾性分析2016年1月至2018年12月在川北医学院附属医院行腹腔镜肝切除术的81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19例，女62例；年龄30～83岁，中位年龄53岁。根据肝胆管结石分型，Ⅰ型61例，Ⅱb型20例。对于Ⅰ型肝胆管结石，切除萎缩的肝叶或肝段。对于Ⅱb型结石，主要切除局限性无功能的肝叶或肝段。观察患者术中及术后并发症发生情况。

所有患者均顺利完成腹腔镜肝切除术。其中肝左外叶切除11例，左半肝切除57例，右半肝切除8例，右后叶切除1例，左外叶切除+ 右前叶切除1例，左外叶切除+ 右后叶上段切除3例。平均手术时间（220±96） min，术中出血量（424±120）ml，术后下床活动时间（2.8±1.1）d，术后进食时间（1.4±0.7） d，术后住院时间（14±6） d。结石残余2例。术中胃肠道损伤4例；术后并发肺部感染12例，胸腔积液20例，肝断面积液9例，其中7例肝断面积液伴感染，胆漏5例，切口感染2例，胃肠功能障碍2例；所有并发症均经保守治愈。

根据患者肝胆管结石分型和结石分布采用个体化治疗，腹腔镜肝切除术对Ⅰ型和Ⅱb型肝胆管结石安全有效，可获得满意疗效。

To evaluate the strategy and efficacy of laparoscopic hepatectomy in the classified treatment of hepatolithiasis.

Clinical data of 81 patients with hepatolithiasis who underwent laparoscopic hepatectomy in the Affiliated Hospital of North Sichuan Medical College from January 2016 to December 2018 were retrospectively analyzed. The informed consents of all patients were obtained and the local ethical committee approval was received. Among them, 19 patients were male and 62 female, aged from 30 to 83 years with a median age of 53 years. According to the classification of hepatolithiasis, 61 cases were classified as type Ⅰ and 20 cases type Ⅱb. The atrophic liver lobes or segments in patients with type Ⅰ hepatolithiasis were resected. For patients with type Ⅱb hepatolithiasis, the limited nonfunctional liver lobes or segments were resected. The incidence of complication during and after operation was observed.

All patients completed laparoscopic hepatectomy successfully. Among them, 11 patients underwent left lateral lobectomy,57 cases left hemihepatectomy, 8 cases right hemihepatectomy, 1 case right posterior lobectomy, 1 case left lateral lobectomy combined with right anterior lobectomy, and 3 cases of left lateral lobectomy combined with the upper right posterior lobectomy. The mean operation time was (220±96) min, the intraoperative blood loss was (424±120) ml, the off-bed time after operation was (2.8±1.1) d, the postoperative eating time was (1.4±0.7) d, and the length of postoperative hospital stay was (14±6) d. Residual stones occurred in 2 cases. Intraoperative gastrointestinal injury occurred in 4 cases. Postoperatively, 12 cases developed pulmonary infection, 20 cases of pleural effusion, 9 cases of hepatic cross-section effusion including 7 cases complicated with infection, 5 cases of bile leakage, 2 cases of incisional infection and 2 cases of gastrointestinal dysfunction. All complications were cured after conservative treatments.

Individual therapeutic strategy should be adopted according to the classification and distribution of hepatolithiasis. Laparoscopic hepatectomy is a safe and efficacious treatment for type Ⅰ and type Ⅱb hepatolithiasis, which can achieve satisfactory clinical efficacy.