胆囊颈部结石嵌顿急性胆囊炎的腹腔镜手术技巧探讨  

Exploration of laparoscopic skills for patients of acute cholecystitis with impacted gallstone

作　　者：所广军[1] 徐安安[1] 靳晓丽[1] 赵欢[1] 谢燕婷[1] 江期鑫[1] 赵中辛[1] 

机构地区：[1]同济大学附属东方医院普外科,上海200120

出　　处：《腹部外科》2015年第2期103-106,共4页Journal of Abdominal Surgery

基　　金：浦东新区科技发展基金资助（PKJ2009-Y21）

摘　　要：目的探索一种主要用普通吸引器协助分离暴露胆囊三角的操作手法在伴胆囊颈部结石嵌顿急性胆囊炎切除术中的有效性。方法2008年1月至2011年2月行腹腔镜胆囊切除治疗胆囊颈部结石嵌顿的急性胆囊炎病人68例，女性38例，男性30例，其中有黄疸者（A组）26例，无黄疸者（B组）42例，两组均经MRCP检查排除胆总管结石。采用微创三孔术式，不用超声刀。术中主要通过吸引器的钝性剥、推及吸引，暴露出胆囊三角。胆囊管及胆囊血管用可吸收缝线结扎。结果所有病例均成功经腹腔镜完成全胆囊切除术，无中转开腹。A组平均手术时间为（59．7±13．4）min，显著长于B组的（30．1±10．7）min，P〈0．01；术中出血量A组为（45．8±16．7）ml，显著多于B组的（20．4±13．5）ml，P〈0．01；A组引流管放置数显著高于B组；A组住院时间显著长于B组。除A组和B组各出现1例术后脐疝外，所有病例均无术后出血、胆漏、胆管损伤、腹腔感染、脐部切口感染及死亡等并发症。结论在熟练掌握腹腔镜手术技巧及经验积累的基础上，采用吸引器等普通腹腔镜器械可以完成结石嵌顿的重症炎性胆囊切除术，避免手术中转或次全胆囊切除；可吸收缝线可避免金属夹引起的并发症和减少手术成本。Objective Acute cholecystitis with impacted gallstone sometimes is rather difficult to deal with laparoscopy. For safety reasons, some surgeons adopt open cholecystectomy （OC） or laparoscopic subtotal cholecystectomy （LSC）. Simple laparoscopic instruments were used with clipless method for complete cholecystectomy to prevent the complications of OC, LSC and metal clip and reduce operative costs. Methods From January 2008 to February 2011, 1,032 laparoscopic cholecystectomies （LC） were performed. Among them, there were 68 cases of acute cholecystitis with impacted gallstone. They were divided into two groups of jaundice （n = 26） and non-jaundice （n = 42） according to the bilirubin level. The operation was performed by general instruments of electrocautery hook, grasping forceps and suction. Instead of metal clip or expensive absorbable hemostasis clip, endoloop, harmonic scalpel and absorbable thread were used for closing cystic duct and gallbladder vessels. Results All cases underwent laparoscopic complete cholecystectomy successfully without OC or LSC. Except for one case of umbilical incision herniation, there was no instance of bleeding, billiary leakage, intra-abdominal infection, umbilical site infection or mortality. Group A had more severe situa- tions compared to group B in mean operative duration, blood loss volume, subhepatic drainage, hospital stay and pathologic results. Conclusions With the improvements of operative skills and handling experiences, simple laparoscopic instruments may be used for performing complete cholecystectomy for patients with acute cholecystitis with impacted gallstone without any conversion into OC or LSC. And closing cystic duct with absorbable thread can avoid the complications of metal clip and reduce operative costs.

关 键 词：腹腔镜胆囊切除 急性胆囊炎 胆囊颈结石嵌顿 

分 类 号：R608[医药卫生—外科学]