腹腔镜胆囊切除术中胆囊破裂的原因及其处理

Cause and management of gallbladder perforation during laparoscopic cholecystectomy

目的 探讨腹腔镜胆囊切除术中胆囊破裂的原因和处理方法。方法 2000年1月～2003年8月,施行腹腔镜胆囊切除术共1024例,回顾术中发生胆囊破裂的176例患者的临床资料,分析其发生原因、处理方法与并发症的关系。结果 本组176例中,因解剖胆囊时抓破18例,自胆囊床剥离时破裂43例,胆囊颈部结石嵌顿先行胆囊穿刺抽吸胆汁减压93例,胆囊萎缩部分切除胆囊16例,胆囊经剑突下穿刺孔取出时破裂6例。136例行腹腔冲洗,其中术后并发膈下积液和胆囊窝积液各2例,剑突下穿刺孔感染4例,剑突下穿刺孔疝1例;40例行小网膜孔填塞,术后无腹腔内与穿刺孔感染发生。结论 小网膜孔预置纱布填塞可减少胆汁在腹腔内扩散;胆囊破裂后及时吸清胆汁,取尽散落的结石,胆囊及胆汁污染的纱布经剑突下穿刺孔取出时使用胆囊袋等措施可减少并发症的发生。

Objective To study the cause and the management of gallbladder perforation during laparoscopic chol-ecystectomy( LC). Methods Between January 2000 and August 2003 , gallbladder perforation occurred in 176 pa-tients during LC among 1024 patients. The cause , management and complication of it were analyzed retrospectively. Results In 176 gallbladder perforation during LC , 18 occurred during dissecting and grasping the gallbladder, 43 during peeling from the gallbladder bed, 93 during puncturing and sucking the bile juice when stone were impacted in the neck of gallbladder, 16 during partial cholecystectomy of small gallbladder, 6 during removal from the portsile subxiphoid. In 136 peritoneal irrigating patients, 2 developed subphrenic fluid, 2 gallbladder fossa fluid, 4 sudxi-phoid portsite infection and 1 hernia of sudxiphoid portsite. In 40 omentum orifice tucking patients, no intraperitoneal and portsite infection found. Conclusion Tucking the lesser omentum orifice with gauze can decrease the bile dif-fusion in peritoneal cavity, clearing the spillage bile juice and stones in time after gallbladder perforation, taking out the contaminated gauze using endoscopic bag, can decrease the incidence of complications.