术前超声检查预测急性胆囊炎腹腔镜胆囊切除术的技术难度

Sonography in acute cholecystitis to predict technical difficulties during laparoscopic cholecystectomy

目的评价术前超声检查预测急性胆囊炎腹腔镜手术技术难度。方法对73例因急性胆囊炎行腹腔镜胆囊切除术的患者行超声检查,超声检测参数:胆囊容积、胆囊壁厚度、胆囊壁增厚类型、结石大小、结石移动性、胆囊与胆囊床的粘连、肝与胆囊间的脂肪厚度、胆囊窝液体、总胆管扩张、总胆管结石、胆囊壁彩色和脉冲多普勒征像、邻近肝脏内的彩色和脉冲多普勒信号。腹腔镜胆囊切除手术分5步,每步根据难易程度记分:困难记1分,容易记0分,总分相加为总的难度分数。评价术前超声表现与总的难度分数、每一步难度分数、手术时间长短是否有显著关系。结果胆囊容积≥ 50 cm3、胆囊壁厚度≥3mm、胆囊壁内丰富彩色血流信号与手术总难度分数显著相关;胆囊容积增大使粘连胆囊及Calot’三角分离困难;胆囊壁增厚及胆囊粘连者胆囊取出腹腔时较难;胆囊壁彩色血流丰富、邻近肝脏血流增加与手术时间延长有显著关系。结论术前测定胆囊容积、胆囊壁厚度、胆囊壁彩色血流丰富程度有助于预测急性胆囊炎腹腔镜胆囊切除手术中的技术难度。

Objective To evaluate the role of preoperative sonography in predicting technical difficulties during laparoscopic cholecystectomy in patients with acute cholecystitis. Methods Sonographic assessment of 14 parameters was performed in 73 patients with acute cholecystitis who underwent laparoscopic cholecystectomy. The Volume of gallbladder （ GB）, thickness of GB wall, pattern of GB wall thickening, size of largest gallstone, gallstone mobility, adhesion of GB to its bed, fat plane between GB and liver, free fluid in GB fossa, common bile duct （CBD） dilatation, CBD stone, color and power Doppler signals in GB wall, and increased color and power Doppler signals in adjacent liver. Each of the 5 operative steps of laparoscopic cholecystectomy was scored as being difficult （ 1 ） or not （0）. The scores for each step were added to obtain the overall difficulty score （0-5）. We evaluated prospectively whether there were significant associations among the preoperative sonographic findings and the overall difficulty score, scores for each of the 5 operative steps, and operative time. Results The overall di^culty score was significantly associated with a GB volume of 50 cm3 or more, GB wall thickness of 3 mm or more, and presence of color Doppler signals in the GB wall. Increased GB volume also made dissection of adhesions from the GB and dissection of Calot＇ s triangle more difficult. Extraction of the GB from the abdomen was more di^cult with a thickened GB wall or adhesion of the GB to its bed. Color Doppler signals in the GB wall, and increased power Doppler signals in the adjacent liver were significantly associated with prolonged operative time. Conclusions Based on our experience, preoperative determination of GB volume, GB wall thickness, and presence of color Doppler signals in the GB wall on patients with acute cholecystitis helps predict technical difficulties during laparoscopic cholecystectomy.