胆囊结石内镜手术学

本书分为基础篇和高级篇两部分，20余万字。基础篇17章，系统介绍了胆道解剖及生理、胆囊结石及息肉的发生机制、保胆手术适应症和禁忌症、保胆手术器械等，并以病例的形式详细介绍了胆囊手术的基本方法、术后治疗及注意事项，包括小切口保胆手术、腹腔镜辅助保胆手术、全腹腔镜下保胆手术、经皮经肝胆囊穿刺术及经瘘道胆道镜取石术等，并对手术并发症及防治、内镜清洗及消毒进行了阐述。高级篇20章，详细介绍了胆囊泥沙样结石、罗-阿氏窦结石、胆囊壶腹部嵌顿结石、胆囊管结石等几种特殊类型的胆囊结石的保胆手术方法，同时阐述了保胆术后结石复发的原因及治疗方法，介绍了皮下通道型保胆取石术、皮下通道型胆囊肝总管成形术、胆囊肝总管成形术等几种特殊的保胆手术方法，并阐述了胆囊结石并胆总管结石、胆囊结石并急性胰腺炎、胆囊结石并胆胰管汇合部疾病等合并症的治疗策略。

杨玉龙， 博士，教授/主任医师，博士生导师、博士后导师，国务院特贴专家，上海市人才引进。现任上海市同济大学附属东方医院胆石中心副主任。历任大连大学中山临床学院副院长、中山医院科研部部长、大外科副主任、肝胆外科主任、省肝胆外科重点专科学科带头人。 中国医师协会内镜医师分会内镜微创保胆专委会副主任委员兼秘书长、青委会主任委员；世界内镜医师协会中国胆胰管内镜协会会长中国中西医协会胆石病专委会副主任委员、中日医学科技交流学会肝胆胰内镜专委会副主任委员，中国非公立医疗机构协会胆石病专委会副主任委员，教育部学位中心论文评审专家、上海科技专家库成员、《中国内镜杂志》、《中国现代医学》、《中国医学工程》、《肝胆胰外科杂志》等期刊编委。发表学术论文160余篇（SCI收录18篇、EI收录2篇），专著4部；获省部级科技进步奖一、二等奖各1项、三等奖2项，市科技进步奖一等奖3项目、二、三等奖各1项；省部级课题3项、市科技局5项；国家发明专利16项、实用新型专利120余项。擅长胆胰内镜微创技术（ERCP\\PTCD\\PTCS）治疗各种原因引起的梗阻性黄疸、胆总管结石、胆管结石、肝胆管结石的手术、胆道镜微创取胆石、内镜微创保留胆囊取石、息肉、内镜微创治疗胆源性胰腺炎；内镜微创解决各种难治的肝内外胆管狭窄、梗阻；内镜微创治疗肝移植术后胆管并发症等。

目　录 上篇　初级篇 第一章　基础解剖 ..................................................................................................................................................................................3 第一节　胆　囊 ........................................................................................................................................................................................................................................3 第二节　肝外胆管 ................................................................................................................................................................................................................................9 第三节　胆胰汇合部 ....................................................................................................................................................................................................................12 第二章　胆道生理 ..............................................................................................................................................................................15 第一节　胆汁代谢 ............................................................................................................................................................................................................................15 第二节　胆囊生理 ............................................................................................................................................................................................................................19 第三节　Oddi括约肌生理 ..................................................................................................................................................................................................22 第三章　胆囊结石 ..............................................................................................................................................................................25 第一节　胆囊结石的病因 ....................................................................................................................................................................................................25 第二节　胆囊结石的形成机制 ....................................................................................................................................................................................27 第三节　胆囊结石 ............................................................................................................................................................................................................................34 第四章　胆囊息肉 ..............................................................................................................................................................................39 第一节　病因及发生机制 ....................................................................................................................................................................................................39 第二节　病理分型 ............................................................................................................................................................................................................................40 第三节　胆囊息肉癌变的高危因素 ..................................................................................................................................................................41 第四节　胆囊息肉 ............................................................................................................................................................................................................................41 第五章　保胆取石/息肉手术内镜设备 ..............................................................................................................43 第一节　内镜设备成像原理及结构 ..................................................................................................................................................................43 第二节　胆道镜 ....................................................................................................................................................................................................................................44 第三节　十二指肠镜 ....................................................................................................................................................................................................................46 第四节　腹腔镜 ....................................................................................................................................................................................................................................48 第六章　保胆取石/息肉手术适应证与禁忌证 ........................................................................................51 第一节　《内镜微创保胆手术指南（2011版）》 ................................................................................................................51 第二节　《现代内镜保胆取石术（2011年）》 ........................................................................................................................52 第三节　《内镜微创保胆手术指南（2015 版）》 ................................................................................................................54 第四节　《内镜保胆手术指南（2021版）》 ................................................................................................................................56 第五节　《胆囊结石内镜手术学（2022版）》 ........................................................................................................................59 第七章　保胆取石/息肉手术前准备 ......................................................................................................................61 第一节　一般准备 ............................................................................................................................................................................................................................61 第二节　生化检查及意义 ....................................................................................................................................................................................................64 第三节　影像学检查及意义 ............................................................................................................................................................................................69 第四节　器械准备 ............................................................................................................................................................................................................................71 第八章　小切口内镜微创保胆取石术 ....................................................................................................................73 第一节　典型病例 ............................................................................................................................................................................................................................73 第二节　手术过程 ............................................................................................................................................................................................................................77 第三节　术后治疗 ............................................................................................................................................................................................................................79 第四节　手术评价及注意事项 ....................................................................................................................................................................................80 第九章　腹腔镜辅助内镜微创保胆取石术 ......................................................................................................81 第一节　典型病例 ............................................................................................................................................................................................................................81 第二节　手术过程 ............................................................................................................................................................................................................................85 第三节　术后治疗 ............................................................................................................................................................................................................................87 第四节　手术评价及注意事项 ....................................................................................................................................................................................88 第十章　腹腔镜下内镜微创保胆取石术 ............................................................................................................89 第一节　典型病例 ............................................................................................................................................................................................................................89 第二节　手术过程 ............................................................................................................................................................................................................................92 第三节　术后治疗 ............................................................................................................................................................................................................................95 第四节　手术评价及注意事项 ....................................................................................................................................................................................96 第十一章　内镜微创保胆息肉摘除术 ....................................................................................................................97 第一节　典型病例 ............................................................................................................................................................................................................................97 第二节　手术过程 ............................................................................................................................................................................................................................99 第三节　术后治疗 ........................................................................................................................................................................................................................101 第四节　手术评价及注意事项 ................................................................................................................................................................................102 第十二章　 开腹胆囊切除术 ..........................................................................................................................................105 第一节　典型病例 ........................................................................................................................................................................................................................105 第二节　手术过程 ........................................................................................................................................................................................................................108 第三节　术后治疗 ........................................................................................................................................................................................................................109 第四节　手术评价及注意事项 ................................................................................................................................................................................110 第十三章　腹腔镜下胆囊切除术 ..............................................................................................................................112 第一节　典型病例 ........................................................................................................................................................................................................................112 第二节　手术过程 ........................................................................................................................................................................................................................115 第三节　术后治疗 ........................................................................................................................................................................................................................117 第四节　手术评价及注意事项 ................................................................................................................................................................................118 第十四章　经皮经肝胆囊穿刺置管引流术 ..................................................................................................121 第一节　典型病例 ........................................................................................................................................................................................................................121 第二节　手术方法 ........................................................................................................................................................................................................................125 第三节　术后治疗 ........................................................................................................................................................................................................................126 第四节　手术评价及注意事项 ................................................................................................................................................................................127 第十五章　经瘘道胆道镜取石术 ..............................................................................................................................131 第一节　典型病例 ........................................................................................................................................................................................................................131 第二节　手术方法 ........................................................................................................................................................................................................................134 第三节　术后治疗 ........................................................................................................................................................................................................................135 第四节　手术评价及注意事项 ................................................................................................................................................................................135 第十六章　保胆取石/息肉手术并发症及防治 ....................................................................................138 第一节　保胆取石手术并发症及其防治 ..............................................................................................................................................138 第二节　保胆取息肉手术并发症及其防治 ......................................................................................................................................142 第三节　经皮经肝胆囊穿刺置管引流术并发症及其防治 ......................................................................................144 第四节　经PTGD/胆囊造瘘管瘘道胆道镜检查并发症及其防治 ..................................................................................147 第十七章　内镜的清洗消毒技术 ..............................................................................................................................149 第一节　内镜清洁消毒标准 ........................................................................................................................................................................................149 第二节　内镜的清洁、消毒、维护和保养 ......................................................................................................................................150 第三节　内镜附件的消毒、灭菌与保存 ..............................................................................................................................................152 第四节　内镜消毒灭菌效果的监测 ..............................................................................................................................................................153 第五节　清洁剂与消毒剂的选择 ......................................................................................................................................................................154 下篇　高级篇 第一章　胆囊沙样结石 ....................................................................................................................................................159 第一节　胆囊泥沙样结石的发生机制 ......................................................................................................................................................159 第二节　泥沙样结石的治疗 ........................................................................................................................................................................................161 第三节　胆道镜用吸附器在泥沙样结石中的应用 ..............................................................................................................163 第四节　泥沙样结石的预防 ........................................................................................................................................................................................165 第二章　胆囊壁间结石 ..........................................................................................................................................................169 第一节　胆囊壁间结石的发生机制 ..............................................................................................................................................................169 第二节　罗-阿氏窦结石的诊断 ......................................................................................................................................................................170 第三节　罗-阿氏窦结石的治疗 ......................................................................................................................................................................170 第四节　罗-阿氏窦结石的保胆取石术 ..............................................................................................................................................171 第五节　手术注意事项及并发症防治 ......................................................................................................................................................172 第三章　胆囊壶腹部嵌顿结石 ......................................................................................................................................174 第一节　等离子碎石技术 ................................................................................................................................................................................................174 第二节　微电极碎石 ................................................................................................................................................................................................................175 第三节　钬激光碎石 ................................................................................................................................................................................................................176 第四章　胆囊管结石 ..................................................................................................................................................................177 第一节　胆囊管结石的诊断 ........................................................................................................................................................................................177 第二节　胆囊管结石的治疗 ........................................................................................................................................................................................179 第五章　胆囊结石复发的原因分析及预防 ..................................................................................................182 第一节　胆囊结石复发的因素 ................................................................................................................................................................................183 第二节　胆囊结石复发的胆囊外因素 ......................................................................................................................................................186 第三节　胆囊结石复发的手术因素 ..............................................................................................................................................................191 第六章　胆囊分隔 ..........................................................................................................................................................................195 第一节　胆囊分隔的发生机制 ................................................................................................................................................................................195 第二节　胆囊分隔的诊断 ................................................................................................................................................................................................195 第三节　胆囊分隔的治疗 ................................................................................................................................................................................................195 第七章　胆囊结石与胆胰汇合部疾病 ................................................................................................................197 第一节　胆囊结石相关性胆胰汇合部疾病 ......................................................................................................................................197 第二节　诊断ERCP技术在保胆取石术中的应用 ..............................................................................................................197 第三节　治疗性ERCP技术在保胆取石术中的应用 ......................................................................................................201 第八章　复发性胆囊结石的处理 ..............................................................................................................................209 第一节　保胆取石术后早期胆囊内絮状物 ......................................................................................................................................209 第二节　保胆取石术后晚期泥沙样结石 ..............................................................................................................................................213 第三节　保胆取石术后晚期成块结石 ......................................................................................................................................................214 第九章　皮下通道型保胆取石术 ..............................................................................................................................216 第一节　皮下通道型保胆取石术设计原理 ......................................................................................................................................216 第二节　手术适应证及禁忌证 ................................................................................................................................................................................216 第三节　皮下通道型保胆取石方法 ..............................................................................................................................................................217 第四节　手术并发症及防治 ........................................................................................................................................................................................217 第五节　复发性胆囊结石的处理 ......................................................................................................................................................................218 第六节　手术疗效评价及注意事项 ..............................................................................................................................................................219 第十章　皮下通道型胆囊肝总管成形术 ........................................................................................................220 第一节　设计原理 ........................................................................................................................................................................................................................220 第二节　手术适应证及禁忌证 ................................................................................................................................................................................221 第三节　手术方式 ........................................................................................................................................................................................................................222 第四节　手术并发症及防治 ........................................................................................................................................................................................223 第五节　复发性胆结石的处理 ................................................................................................................................................................................226 第六节　手术疗效评价 ........................................................................................................................................................................................................226 第十一章　胆囊肝总管成形术 ......................................................................................................................................228 第一节　设计原理 ........................................................................................................................................................................................................................228 第二节　手术适应证及禁忌证 ................................................................................................................................................................................229 第三节　主要手术步骤 ........................................................................................................................................................................................................229 第四节　手术并发症及防治 ........................................................................................................................................................................................230 第五节　复发性胆结石处理 ........................................................................................................................................................................................231 第六节　手术疗效评价 ........................................................................................................................................................................................................232 第十二章　特殊类型保胆取石/息肉术 ..........................................................................................................233 第一节　隐瘢痕腹腔镜下保胆取石/息肉术 ................................................................................................................................233 第二节　单孔腹腔镜下保胆取石/息肉术 ........................................................................................................................................233 第三节　经自然腔道保胆取石/息肉术 ................................................................................................................................................234 第十三章　胆囊结石并胆总管结石治疗策略 ..........................................................................................235 第一节　开腹胆道探查保胆取石术 ..............................................................................................................................................................235 第二节　腹腔镜下胆道探查保胆取石术 ..............................................................................................................................................239 第三节　腹腔镜联合十二指肠镜保胆取石术 ..............................................................................................................................243 第四节　十二指肠镜联合经皮经肝胆囊穿刺扩管取石术 ......................................................................................244 第十四章　胆囊结石并胆源性胰腺炎治疗策略 ..................................................................................248 第一节　胆源性胰腺炎 ........................................................................................................................................................................................................248 第二节　胆源性胰腺炎的发病机制 ..............................................................................................................................................................249 第三节　胆源性胰腺炎的内镜治疗 ..............................................................................................................................................................250 第四节　胆源性胰腺炎是否应该切除胆囊 ......................................................................................................................................252 第十五章　胆囊结石并隐匿性胰胆反流的治疗策略 ....................................................................254 第十六章　急性非结石性胆囊炎的治疗策略 ..........................................................................................257 第十七章　经胆道镜控制性加压冲洗 ................................................................................................................260 第一节　经胆道镜控制性加压冲洗 ..............................................................................................................................................................260 第二节　控制性加压冲洗的意义 ......................................................................................................................................................................261 第十八章　全身麻醉术中胆囊压力测量的意义 ..................................................................................263 第一节　胆囊压力 ........................................................................................................................................................................................................................263 第二节　全身麻醉术中胆囊压力的测量 ..............................................................................................................................................264 第三节　 胆囊压力在诊断胆囊管结石中的作用 ....................................................................................................................265 第十九章　胆胰汇合部疾病的临床思考和诊治策略 ....................................................................267 第一节　胆胰汇合部 ................................................................................................................................................................................................................268 第二节　胰胆管合流异常 ................................................................................................................................................................................................268 第三节　十二指肠乳头旁憩室 ................................................................................................................................................................................269 第四节　Oddi 括约肌功能障碍 ..............................................................................................................................................................................270 第二十章　胰胆反流临床分型及治疗策略 ..................................................................................................273 第一节　解剖基础及临床研究 ................................................................................................................................................................................273 第二节　病理改变及相关疾病 ................................................................................................................................................................................274 第三节　胰胆反流临床分析 ........................................................................................................................................................................................275 第四节　胰胆反流临床治疗 ........................................................................................................................................................................................276