腹腔镜胆囊切除术中胆囊颈管入路H形解剖法的解剖学基础及临床应用研究

目的:观察胆囊三角区内胆管、胆囊动脉的解剖特点,并应用于临床实践,确定胆囊三角恰当的处理方式,避免腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)并发症的发生。方法:采用经常规防腐处理的成人尸体标本52具,先以H形解剖法浆膜下游离胆囊颈管,行胆囊三角区显微解剖,观测胆囊动脉的起始、走行、分支分型、进入胆囊的位置及与周围结构的解剖关系,以及胆囊管汇入胆总管的方式、位置,并应用于76例LC术中,观察其手术效果。结果:尸体解剖中经胆囊颈管H形解剖法显露的胆囊颈管浆膜下尸体解剖及术中均未发现胆管、血管。尸体解剖中见经右肝前、后动脉及胃十二指肠动脉发出异位胆囊动脉(分别为2例、4例及3例),多支型胆囊动脉与胆囊管伴行支及胆囊管后支(5例),平行型胆囊管(10例)。LC术中经H形解剖胆囊颈入路完成73例,胆囊颈管与壶腹连接处均无紧密粘连,经右肝前、后动脉及胃十二指肠动脉发出异位胆囊动脉分别为1例、2例、2例,多支型胆囊动脉与胆囊管伴行支及胆囊管后支4例,平行型胆囊管6例,胆囊管汇入右肝管2例,向后汇入肝总管后壁2例。全组均无肝外胆管损伤。结论:经胆囊颈管H形解剖法是LC的安全入路,利于辨清胆囊三角内的解剖结构及变异,可有效避免LC并发症的发生,具有较好的临床应用价值。

Study on anatomical basis and clinical application of dissection of gallbladder neck with H form in laparoscopic cholecystectomy

Objective：To observe the bile duct and blood vessel distribution characteristics of gallbladder triangle and its ana- tomical relationship with surrounding structures, and to apply in clinic so that appropriate intraoperative treatment can be determined and the occurrence of surgical complications can be prevented. Methods ： Fifty-two adult embalmed corpse specimens were subjected to microdissection at the gallbladder triangle zone using the operative approach of H form. The beginning,line going, branch points of gall- bladder artery and its location entering gallbladder, and anatomical relationship with surrounding structures, as well as the way and loca- tion of the cygtic duct into the common bile duct were observed. This approach was applied to 76 patients undergoing laparoscopic chole- cystectomy, and then the operation effects were observed. Results ： No bile ducts and vessels were found under the gallbladder ampulla using the operative approach of H form. The ectopic gallbladder artery origining from the anterior and posterior artery of the right liver and gastroduodenal artery had a certain probability （2 cases ,4 cases and 3 cases）, the plurality of gallbladder artery accompanied with the cystic duct and posterior branch of bile duct （5 cases）, and the parallel type duct （ 10 cases） in postmortem were found. All opera- tions succeeded without death,73 of which were done by approach with H form. No tight adhesion was found at the junction of the neck and ampulla of gallbladder. The data of the operations were 1 case,2 cases ,2 cases,4 cases and 6 cases respectively. The cystic duct drained into the right hepatic duct （2 cases） and posteriorly drained into the posterior wall of the common hepatic duct （2 cases）. All patients were cured and no extrahepatic bile duct injuries occurred. Conclusions：The surgical approach which dissects posterolateral region of gallbladder neck combined gallbladder triangle in H form can clarify the anatomic structure and variation in Calot triangle,