急性胆囊炎的腹腔镜手术治疗体会(附212例报告)

目的总结急性胆囊炎行腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)的经验。方法 2004年1月~2009年1月,对212例急性胆囊炎行LC。术中行胆囊减压,将胆囊颈部嵌顿的结石反向推至胆囊内,恢复胆囊三角的解剖关系,紧贴胆囊颈分离解剖胆囊管和胆囊动脉;对增粗的胆囊管用7号丝线结扎后再加钛夹或可吸收夹;胆囊局部病变重,胆囊三角解剖不清者,行胆囊大部切除,残余胆囊黏膜电凝破坏,缝合胆囊残端;对短胆囊管,在明确胆囊管、肝总管和胆总管的关系后用1枚钛夹夹闭胆囊管,离断时留部分胆囊颈组织以防钛夹脱落。212例术后均放置腹腔引流管。结果 201例完成LC,11例中转开腹,其中Mirizzi综合征Ⅰ型2例,胆囊与胃、十二指肠、横结肠紧密粘连2例,7例为胆囊三角粘连严重,解剖不清。4例术后胆漏,经保守治疗痊愈。186例随访1~12个月,平均4.6月,无胆总管残余结石等并发症。结论 LC治疗急性胆囊炎是安全可行的,严格病例选择,酌情处理胆囊三角、胆囊管和分离胆囊,常规放置引流管,适时中转开腹是手术成功的关键。

Experience on Laparoscopic Cholecystectomy for Acute Cholecystitis: Report of 212 Cases

Objective To summarize our experience of laparoscopic cholecystectomy（LC）in the treatment of acute cholecystitis.Methods Totally 212 cases of acute cholecystitis underwent LC in our hostpial from January 2004 to January 2009.During the operation,we performed intraoperative gallbladder decompression to the impacted stone back into the gallbladder,and restore the anatomical relationship of the Calot triangle.Afterwards,the cystic duct and cystic artery closed to the gallbladder neck were separated,and titanium or absorbable clips was used after ligation of the thickening cystic duct with 7# suture;in patients with local heavy disease and unclear triangle anatomy,the residual gallbladder underwent electrocoagulation to destroy the mucosa and then the gallbladder stump was sutured;for patients with short cystic duct,we used a titanium clip to sever the cystic duct after exploring the relationship among the cystic duct,hepatic duct and common bile duct,the gallbladder neck was remained to prevent the titanium clip from falling off.Abdominal drainage was employed in all of the patients postoperatively.Results LC was completed in 201 patients,the other 11 patients were converted to open surgery because of Mirizzi syndrome type Ⅰ（2 cases）,close adhesion between the gallbladder,stomach,duodenum,and transverse colon（2 cases）,and severe adhesion of the gallbladder triangle resulting in an unclear anatomy（7 cases）.Four patients developed biliary leakage after the surgery and was then cured by conservative therapy.Totally 186 patients received follow-up for 1-12 months（mean,4.6 months）,during which no residual stones or complications occurred.Conclusions LC is feasible and safe for patients with acute cholecystitis.Deep understanding of LC technique,correct position for abdominal drainage and appropriate time for conversion to open surgery are keys to success of the operation.