急性胆囊炎行腹腔镜胆囊切除术与胆道损伤

目的:探讨急性胆囊炎行腹腔镜胆囊切除术(lapa-roscopic cholecystectomy,LC)中胆道损伤的预防措施。方法:2007年4月～2012年4月对118例急性结石性胆囊炎患者在四孔法下行LC。紧贴胆囊壶腹与胆囊管移行部使用电凝及吸引器精准解剖Calot三角,先游离后三角内脂肪、纤维和结缔组织,再解剖前三角,使前后三角贯穿。Calot三角内只有胆囊管和胆囊动脉管状结构,进入肝十二指肠韧带,紧贴胆囊壁夹闭动脉并切断,缘胆囊壶腹部确定胆囊管后夹闭胆囊管并切断。结果:113例完成LC,5例中转开腹行胆囊切除术。其中Mirrize综合征Ⅰ型1例;Calot三角致密粘连难以分离2例;胆囊管明显增粗、结石嵌顿,疑胆总管继发结石2例。术后戳孔感染4例;肺部感染1例;心律失常1例;戳孔疝1例;胆漏1例,经腹腔引流1周后治愈;胆囊床出血1例,第2日腹腔镜止血治愈;胆总管残石1例,1月后行EST去除;无胆管、血管损伤。结论:急性胆囊炎LC中,应用此方法解剖Calot三角,缘胆囊壶腹部确定胆囊管后夹闭并切断,能有效预防胆道损伤。

Preventing bile duct injury in patients with acute cholecystitis undergoing laparoscopic cholecystectomy

Objective:To investigate an effective way to prevent the bile duct injury in patients with acute cholecystitis undergoing laparoscopic cholecystectomy(LC).Methods:Between Apr.2007 and Apr.2012,118 inpatients of acute cholecystitis underwent LC by making four holes in the abaominal wall.Initially,anatomical exposure of the Calot′s triangle area was carefully performed closely near the duodenal ampulla of the gallbladder and transitional zone using electrocoagulation and suction unit.Removal of the fat,fiber tissues and connective tissues were carried out sequentially in the area around the gallbladder.Transfixion was made anteroposteriorly through Calot′s triangle by route of hepatoduodenal ligament to identify the artery and cystic duct that were then clipped and cut off.Results:In the total 118 cases,LC was successfully performed in 113,and 5 required referral to open cholecystectomy in which one case was associated with type I Mirrize syndrome,2 with difficult dissection of the Calot′s triangle and another 2 with significantly enlarged cystic duct and incarcerated stones,who were suspected secondary common bile duct stone.Postoperative complications were associated with infection in 4 cases due to stabbed hole,lung infection in 1,arrhythmia in 1,trocar site hernia in 1and bile leakage in another 1 that was managed in one week of abdominal drainage.One case was complicated with bleeding from the gallbladder bed,which was managed with laparoscopic hemostasis by the second day.Residual stones in common bile duct occurred in one case,which was removed by EST one month later.No bile duct or blood vessel injury occurred in the total 118 cases.Conclusion:The dissection of Calot′s triangle in LC for treatment of acute cholecystitis described in our experience may effectively prevent the bile duct from injury.