腹腔镜下复杂胆囊三角的处理体会(附668例报告)

目的:探讨腹腔镜下复杂胆囊三角的处理技巧。方法:回顾分析2000年2月至2011年10月为668例复杂胆囊患者行腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)的临床资料,对萎缩性胆囊炎、胆囊管结石、急性胆囊炎等复杂情况采取相应的手术技巧,细致解剖胆囊三角。结果:644例顺利完成LC;24例中转开腹,其中Mirizzi综合征Ⅱ～Ⅳ型5例,胆囊三角致密粘连15例,胆囊十二指肠内瘘2例,胆管损伤行胆管修复及T管引流2例,分别于术后6个月、12个月拔除T管。16例术后发生胆漏,均保守治愈。术后随访,无严重并发症发生。结论:腹腔镜复杂胆囊切除术中细致解剖胆囊三角是手术成功的关键,胆囊三角致密粘连、Mirizzi综合征Ⅱ型～Ⅳ型或内瘘形成等是中转手术的指征。

The management of complex Calot triangle during laparoscopic cholecystectomy: with a report of 668 cases

Objective:To discuss the operative skills of complex Calot triangle in laparoscopic cholecystectomy(LC).Methods:The clinical data of 668 patients with complex Calot triangle who underwent LC from Feb.2000 to Oct.2011 were studied retrospectively.Corresponding procedures were conducted according to the actual situation,such as atrophy cholecystitis,calculus of cystic duct and acute cholecystitis.The gallbladder triangle was carefully dissected.Results:The 644 of 668 cases were operated successfully.24 cases were converted to open surgery,in which there were 5 cases of Mirizzi Ⅱ-Ⅳ syndrome,15 cases of Calot triangle compact adhesion,2 cases of gallbladder-duodenum internal fistula and 2 cases of bile duct injury.The 2 patients who suffered intraoperative bile duct injury were treated with repair and T-tube drainage which was removed 6 or 12 months after the operation.All 16 cases of postoperative bile leakage were cured through conservative therapy.All patients were followed up after surgery,there were no other serious complications.Conclusions:Detailed gallbladder triangle anatomy is important in complex LC.With accumulation of operative experiences and improvements in technology,LC is feasible to treat atrophic cholecystitis.But tight adhesion of Calot triangle,Mirizzi Ⅱ-Ⅳ syndrome and internal fistula formation are the indications for open surgery.