胆道镜课件

泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE胆胆 道道 镜镜泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科 1泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE一、概述2泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE1.硬性胆道镜（1）胆管镜 （2）胆囊镜2.软性胆道镜（纤维胆道镜）：（1）纤维胆管镜 （2）子母镜胆道镜分类：3泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE1）胆管镜：呈L形，壁长：18cm,横臂长7cm.外径 8mm2）胆囊镜：配有镜鞘，侧方有目镜，外径12mm，内有直径7.5mm孔道。超声发生器工作频率27000Hz，超声探头：长400mm，外径5.5mm，中央孔道：4mm。手术器械：硬性胆道镜：4泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE（1）子母镜：1)、十二指肠镜：14.5mm，孔道5.5mm 2)、子镜：2.84.0mm，孔道1.7mm 双向转角，向上160度，向下100度（2）纤维胆管镜：工作长3545cm,外径3.54.9mm，孔道1.22.2mm，视野：120度，景深：350mm软性胆道镜（纤维胆道镜）：5泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE 1、术前胆道镜（经皮经肝胆道镜）；2、术中胆道镜；3、术后胆道镜；4、经口胆道镜（子母镜）。胆胆 镜镜 技技 术术 分分 类类6泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE一、术 后 胆 道 镜7泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE1.适应症 1、已知或可疑胆道残余结石；2、胆道肿瘤或可疑胆道占位性病变，需取病理确诊；3、胆道晚期肿瘤，伴梗阻性黄胆需胆镜下治疗；4、胆道畸形或狭窄；5、胆道蛔虫；6、胆道出血；7、胆道异物；8、选择性胆管造影；9、硬化性胆管炎；是一种唯一可靠的诊断方法 10、胆道动力学研究。8泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE2.禁 忌 症 1、有明显出凝血机能异常者慎用；2、有严重心肺功能不全者慎用；3、胆道以外原因导致发热者应暂停胆道镜检查。3.手术同意书胆道镜检查手术同意书（泸医附院）9泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE3.术 前 准 备1、冷光源、纤维胆道镜、取石网篮、活检钳等附件；2、静脉输液器一套；3静脉用生理盐水30005000ml（加抗生素）；4、准备1626Fr 引流管（消毒备用）；5、消毒铺巾及敷料等；6、按无菌操作进行，穿戴无菌手术衣帽 和手套。拔T管后手术野消毒铺巾。10泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE11泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE纤 维 胆 道 镜 消 毒灭 菌：（1）2%戊二醛液，浸泡时间为10小时以上 （2）等离子消毒灭菌 （3）环氧乙烷附件（取石网、活检钳）消毒灭菌：（1）2%戊二醛液，浸泡时间为30分钟以上（2）等离子消毒灭菌（3）环氧乙烷12泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE胆道镜的入路1、经T型管窦道；2、经U型管窦道；3、胆囊造瘘术后窦道；4、肝内胆管造瘘术后窦道；5、胆肠吻合口；6、空肠盲袢皮下造瘘术后窦道。13泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE胆道镜检查方法1.先消毒铺无菌巾，戴无菌手套。2.将静脉输液器与胆镜连接，边注水边入镜检查。3.先检查肝外胆管，然后顺序检查肝内胆管各分支。4.胆镜通过狭窄部或Oddi 括约肌开口时不能用暴力，否则会造成撕裂出血，亦可损伤胆镜。胆道镜操作规范（泸医附院）胆道镜手术记录（泸医附院）14泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE检查注意事项检查时注意胆管粘膜有无充血、水肿、糜烂、溃疡；Oddi括约肌开口有无炎症、梗阻。胆镜能否通过。肝内外胆管有无扩张、狭窄、结石、肿瘤、蛔虫、异物或血块；发现病变时应做相应处理。15泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE胆镜下正常胆管粘膜图像 肝内胆管正常粘膜图像：粘膜光滑，淡红色，分支明显，管腔呈圆形或椭圆形，可见新鲜胆汁分泌。16泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE胆镜下正常胆管粘膜图像17泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE胆镜下正常胆管粘膜图像 肝外胆管正常粘膜图像：胆总管粘膜光滑，淡红色，末端粘膜呈绒毛状，开口可见舒缩运动，呈放射状。胆囊管开口位于肝外胆管，呈半月形。泸州医学院附属医院肝胆外科 18泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE胆镜下正常胆管粘膜图像19泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE胆镜下正常胆管粘膜图像泸州医学院附属医院肝胆外科 20泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE胆镜下胆管病变图像 1.胆管炎：充血，水肿，出血，糜烂，溃疡，脓液，团块状絮状、慧星状物，管腔呈扁平状，不规则 状，扩张，狭窄。泸州医学院附属医院肝胆外科 21泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE胆镜下胆管病变图像（胆管炎）泸州医学院附属医院肝胆外科 泸州医学院附属医院肝胆外科 22泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE胆镜下胆管病变图像（胆管炎）泸州医学院附属医院肝胆外科 泸州医学院附属医院肝胆外科 23泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE胆镜下胆管病变图像（胆管狭窄）泸州医学院附属医院肝胆外科 24泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE胆镜下胆管病变图像 硬化性胆管炎 胆管僵硬，无弹性，管腔不扩张，粘膜充血水肿。25泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE胆镜下硬化性胆管炎图像泸州医学院附属医院肝胆外科 泸州医学院附属医院肝胆外科 26泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE胆镜下胆管病变图像（胆管肿瘤）（1）息肉：球形或半球形隆起，光滑，活检病理可确诊；27泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE（2）胆管腺癌1）肿块型：呈菜花样，组织脆，触碰易出血，病理可确诊2）浸润型：沿管壁浸润性生长，表现为管腔狭窄胆镜下胆管病变图像（胆管肿瘤）28泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE胆镜下胆管病变图像（胆胆镜下胆管病变图像（胆管肿瘤）管肿瘤）泸州医学院附属医院肝胆外科 泸州医学院附属医院肝胆外科 29泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE胆镜下胆管病变图像（胆胆镜下胆管病变图像（胆管肿瘤）管肿瘤）泸州医学院附属医院肝胆外科 泸州医学院附属医院肝胆外科 30泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE胆镜下胆管病变图像（胆胆镜下胆管病变图像（胆管肿瘤）管肿瘤）泸州医学院附属医院肝胆外科 泸州医学院附属医院肝胆外科 31泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE胆镜下胆管病变图像（胆胆镜下胆管病变图像（胆管肿瘤）管肿瘤）泸州医学院附属医院肝胆外科 泸州医学院附属医院肝胆外科 32泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE胆镜下胆管病变图像（胆胆镜下胆管病变图像（胆管肿瘤）管肿瘤）泸州医学院附属医院肝胆外科 33泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE胆总管呈球囊状扩张，管腔宽大。光线暗淡，腔内见大量絮状物和结石。肝内胆管亦呈囊状扩张。胆镜下先天性胆总管囊肿34泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE 术后四周 粘膜充血水肿，吻合口有白苔、缝线头。术后三月左肝外叶切除术后改变35泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE左肝外叶切除术后改变泸州医学院附属医院肝胆外科 泸州医学院附属医院肝胆外科 36泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE胆肠吻合口：下方为十二指肠，上方为胆管。吻合口见有残存的缝线头。胆肠吻合口37泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE肝内胆管扩张：正常胆管：右肝管长8.8mm，管径3.5mm;左肝管长14.9mm，管径3.3mm。胆管扩张38泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE肝外胆管扩张：正常胆管：肝总管长34cm管径5mm;胆总管长79cm,管径0.60.8cm胆管扩张39泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE结石：可确定胆石大小、形状、颜色、以及与胆管的关系、嵌顿。胆管狭窄泸州医学院附属医院肝胆外科 40泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE胆管狭窄泸州医学院附属医院肝胆外科 泸州医学院附属医院肝胆外科 41泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE 1、网篮取石法：发现胆石时，将取石篮自操作孔道插入，越过胆石再张开网篮，来回移动网篮，将胆石套住。再将取石篮和胆镜一起慢慢退出。胆镜术后继续放置胆道引流管经胆道镜取石42泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE胆管壁固醇沉积泸州医学院附属医院肝胆外科 泸州医学院附属医院肝胆外科 43泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE胆管结石伴胆管炎泸州医学院附属医院肝胆外科 泸州医学院附属医院肝胆外科 44泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE胆 管 结 石泸州医学院附属医院肝胆外科 泸州医学院附属医院肝胆外科 45泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE1、继续留置T管2、告知病人注意保护好T管，以免脱出。3、一周后复查术后处理46泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE1、结石大：扩展窦道 碎石：*手术钳碎石 *活检钳碎石 *激光碎石 *液电碎石2、胆管狭窄；1）胆镜或小胆石扩张法 2）气囊扩张法取石困难的常见原因及处理方法47泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE1、结石大：扩展窦道 碎石：*手术钳碎石 *活检钳碎石 *激光碎石 *液电碎石2、胆管狭窄；1）胆镜或小胆石扩张法 2）气囊扩张法 3、小胆石不易入网：冲洗法4、窦道过长、过细、弯曲：5、胆肠吻合经皮空肠造瘘术后取石困难的常见原因及处理方法48泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE胆管结石（体内微爆破碎石）泸州医学院附属医院肝胆外科 泸州医学院附属医院肝胆外科 49泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE胆 管 狭 窄50泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE1、发热：多为一过性的低热，应保持胆道引流通畅。2、窦道穿孔：多发生在术后过早取石，入镜或取石用力过猛所致，也可因窦道在腹腔过长、扭曲，换管时用较大的引流管所致。预防：胆镜检查应在术后4周以后进行；胆镜取石应在术后6周后进行。3、恶心、呕吐：胆道镜检查肝内胆管或对Oddi口的刺激或滴注液体过快时均可导致。停止操作可缓4、腹泻：生理盐水用量过多所致。液体用量应控制在3000ml左右，不宜过多。5、胆道出血：门脉高压症，或因胆石压迫胆管粘膜致坏死、潰疡，取石后易致出血。6、膈下或肝下积液、取石网被卡或断裂、胆道引流导管脱出、十二指肠穿孔胆道镜术后并发症51泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE（一）、术中胆道镜的适应症：1、术前胆道疾病诊断不明，疑有胆道占位性 病变，需术中明确诊断，如胆管梗阻狭窄，需取活检，以便术式选择；2、术前与术中诊断不符；3、肝内胆管结石量不多，手术取石困难时，可用术中胆镜取石；可确诊胆石是否取净。4、胆囊造瘘取石，易遗漏胆管结石，可应 用纤胆镜检查；5、腹腔镜下胆总管切开取石，可行术中胆 镜检查取石。二、术 中 胆 道 镜52泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE 1、仪器：可应用纤维胆道镜或硬性胆道镜。2、入路：可经胆囊造口、肝胆管造口或胆 总管造口或肝叶切除后断面胆管处直接 进入胆道。3、方法：依次检查肝内胆管各分支，然后 检查肝外胆管。注意胆管有无炎症、肿块、狭窄,结石，并给予相应的处理。术 中 胆 道 镜 的 方 法53泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE术 中 胆 道 镜 的 优 缺 点 1、优 点：（1）降低胆道术后残余结石发生率；（2）术中有助于对病变的确诊，为手术方式的选择提供依据。2、缺 点：（1）术中胆道镜操作不太方便，取石不如术后胆道镜容易掌握；（2）使伤口显露的时间延长以及盐水和胆汁外溢易污染腹腔；（3）腹腔镜胆总管切开取石使用纤维胆道镜时，易损伤胆道镜。54泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE胆道镜发现胆总管下端结石55泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE胆道镜发现胆总管下端结石56泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE胆道镜发现胆总管下端结石57泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE胆道镜网篮取石58泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE胆道镜网篮取石59泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE胆道镜网篮取石60泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE胆道镜网篮取石，结石已取出61泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE胆道镜网篮取石，结石已取出62泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE胆道镜探查胆总管下端括约肌功能63泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE再次探查上段胆管有无结石残留 64泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE经皮经肝胆道镜（PTCS）是指先行经皮经肝胆道穿刺引流术（PTCD），继之进行PTCD窦道扩张术，待窦道被扩张到能容纳胆道镜进入胆道时，再进行纤维胆道镜检查和治疗。三、经三、经 皮皮 经经 肝肝 胆胆 道道 镜镜（PTCS）65泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE 适应症：1、梗阻性黄胆经各种影像学检查提示有肝内胆管扩张而不能确诊；2、胆管肿瘤未能确诊者；3、胆管狭窄伴肝内胆管扩张；4、胆肠吻合口狭窄；5、胆管畸形。禁忌症：1、肝内胆管不扩张；2、出凝血机能异常；3、严重心肺功能不全；4、肝硬化门脉高压者。经经 皮皮 经经 肝肝 胆胆 道道 镜镜（PTCS）66泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE经经 皮皮 经经 肝肝 胆胆 道道 镜镜（PTCS）1、术前准备：（1）术前检查血常规及出凝血时间；（2）在B超引导下或X线透视监视下行PTCD。（3）PTCD窦道扩张术：在其术后一周开始窦 道扩张，以后每周一次。一般扩张4 次后，可容纳16-18Fr 扩张探子进入即可进行胆 道镜检查和治疗。（4）其他准备同术后胆道镜。67泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE经经 皮皮 经经 肝肝 胆胆 道道 镜镜（PTCS）2、PTCS检查方法 胆镜自经皮肝窦道进入胆管，先寻找确认肝门部，依次检查总肝管，胆总管，以及Oddi括约肌开口部，然后检 查肝内胆管 其他方法与术后胆道镜相同。68泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE经经 皮皮 经经 肝肝 胆胆 道道 镜镜（PTCS）的）的 并并 发发 症症 1、胆道出血：多发生在出凝血机能异常的患者，在穿刺肝实质或扩张窦道时发生，也可因拉取较大结石时发生。2、胆漏或胆汁性腹膜炎：一般发生在穿刺或更换引流管过早或引流管脱落时。3、发热：为一过性，应保持引流管通畅，必要时用抗生素。4、悪心、呕吐：一般发生在进行窦道扩张时或检查、取石过程中，注水过快刺激所致。5、心血管意外69泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE胆管狭窄（经皮经肝球囊扩张）70泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE经 胆 道 镜 碎 石 术71泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE液液 电电 碎碎 石石 术术 液电碎石（Electrohydraulic lithotripsy;EHL）是治疗大胆石和嵌顿胆石的一种有效而安全的方法。直视下碎石。可用于：1）经口胆道镜、2）经皮肝胆道镜 3）经T管窦道胆镜72泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE液液 电电 碎碎 石石（EHL）仪）仪 器器高压发生器、足踏开关、输出导线、高压放电探头胆道镜73泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE液液 电电 碎碎 石石（EHL）的）的 方方 法法1、从活检孔道插入高压放电碎石探头，并将其接触胆石。2、助手将碎石器电源接通，选择好所需放电频率和强度。3、在连续注水情况下，使胆石完全浸泡在液体中，术者启动足踏开关放电，将胆石击碎。4、每次放电12秒钟。如一次未能击碎胆石，可多次重复放电，直至击碎成可取出的小块为止74泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE 微爆破碎石术是利用微量炸药定向、定点爆炸来破碎结石的一种方法。可应用于胆道和泌尿道的大结石及嵌顿结石。微微 爆爆 破破 碎碎 石石 术术75泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE1、微爆破器2、起爆器3、胆道镜4、用药量1.02mg微微 爆爆 破破 碎碎 石石 仪仪 器器 设设 备备76泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE微微 爆爆 破破 碎碎 石石 仪仪 器器 设设 备备77泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE超声碎石是利用一种晶体将高频电能转换成机械震动的超声波，金属棒头的声头传导超升能，作用于结石，使之产生很强的高频震动进行碎石。内内 镜镜 下下 超超 声声 碎碎 石石78泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE1、专用硬质碎石镜2、超声发生器3、超声碎石器 1）鞘管，2）声头，3）手柄4、吸引器5、脚踏开关内内 镜镜 下下 超超 声声 碎碎 石石 仪仪 器器 设设 备备79泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE一、普通激光碎石：染料激光、钬激光二、双频双脉冲激光碎石技术参数：激光波长：532nm和1064nm激光脉冲能量：120mJ激光脉冲持续时间：1.2s(在1064nm时)激光脉冲重复频率：可调1、3、5、10Hz激激 光光 碎碎 石石80泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE是一种钕-YAG激光，有波长为1064m的不可见红光（80%）和532m的绿光（20%）组成。激光仪发射出的激光经光纤把激光束能量打到结石表面，绿光部分被结石表面吸收，在结石表面形成等离子体，等离子体再吸收不可见的红光后崩裂，产生的冲击波粉碎结石。属一种机械性的碎石作用。双双 频频 双双 脉脉 冲冲 激激 光光 碎碎 石石 原原 理理81泸州医学院附属医院肝胆外科泸州医学院附属医院肝胆外科THE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGETHE AFFILIATED HOSPITAL OF LUZHOU MEDICAL COLLEGE适应症及特点：适应症及特点：1、安全：对组织损伤小，不穿孔（直接打在输尿管上2000次无穿孔）。2、碎石效率高：是普通激光碎石的6倍。3、适用于泌尿系结石、胆道结石和唾液腺结 石。双双 频频 双双 脉脉 冲冲 激激 光光 碎碎 石石82docin/sanshengshiyuandoc88/sanshenglu 更多精品资源请访问更多精品资源请访问83