困难性腹腔镜胆囊切除术手术方法探讨

目的探讨困难性腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）的手术处理技巧。方法回顾分析我院2006年3月～2008年12月完成的201例困难性LC手术资料,包括胆囊周围包囊粘连107例,胆囊三角区致密粘连、解剖困难75例,胆囊颈部结石38例,胆囊化脓坏疽11例,胆囊萎缩18例,上腹部手术史17例。结果193例完成腹腔镜手术,8例（4.0%）中转开腹,原因包括：3例胆囊三角区出血止血困难;2例胆囊与结肠、胃及十二指肠粘连致密无法分离显露胆囊,胆囊坏疽;2例胆囊管近汇合部后壁轻度撕裂伤致胆漏;1例胆囊三角区呈＂冰冻＂状难以解剖。无胆管损伤及术中大出血。术后并发症3例（1.5%）,包括胆囊三角区出血1例,机械性肠梗阻二次手术1例,肺部感染、呼吸功能衰竭1例,均治愈。全组无死亡。结论对困难性LC,应始终遵循＂解剖紧贴胆囊,切前辨清关系,钝锐交替分离,顺逆结合切除＂的原则,有上腹部手术史则用开放法建立气腹,分离腹腔粘连。

Experiences in Difficult Laparoscopic Cholecystectomy

Objective To report our experiences in difficult laparoscopic cholecystectomy （LC）. Methods The clinical data of 201 cases of difficult LC performed from March 2006 to December 2008 were analyzed retrospectively, and the surgical operation approaches were summarized. The cases included 107 patients with pyknotic conglutination around the gallbladder or gallbladder triangle area, 38 patients with gallbladder neck stone, 11 patients with suppuration or gangrene of the gallbladder, 18 patients with atrophy of the gallbladder, and 17 patients with operation history in the upper abdomen. Results The LC was completed in 193 of the cases, the other 8 cases were converted to open surgery. The causes for conversion to open surgery included intractable bleeding at the gallbladder triangle in 3 patients, the gallbladder being covered by stomach, colon and duodenum in 1, gallbladder gangrene in 1, bile leakage resulted from slightly lacerations of the posterior wall at the confluence of the gallbladder and bile duct in 2, and frozen likeness of the gallbladder triangle in 1. The complications of LC included intestinal obstruction （ 1 case） , pulmonary infection with respiratory dysfunction （1 case） , and postoperative bleeding （1 cases）. No extrahepatic bile duct injury and death occurred in this series. Conclusions For difficult LC, we must abide by the rules as follows： to dissect as far as possible adjoin to the gallbladder; to discriminate the tissues or organs before cutting it; to execute LC in combination with mute and acuminate dissection and antegrade and retrograde approach for resection; to make pneumoperitoneum through a small incision for patients with history of operations in the upper abdomen. Only obey the laparoscopic surgical principle and use correct surgical approaches, can we reduce the incidence rates of complications and conversion to open surgery.