巨大胆囊结石的腹腔镜胆囊切除术56例

Laparoscopic cholecystectomy in patients with huge gallstones: A report of 56 cases

目的探讨巨大胆囊结石腹腔镜胆囊切除术（laparoscopic cholecystectomy，LC）的难点及对策。方法回顾性分析56例结石最大径2．0～5．3cm（3．4±0．6）cm的巨大胆囊结石的临床特征、LC的难点及处理方法。结果54例顺利完成LC，手术时间30～130min，（94．3±40．7）min；2例（4％）由于急性化脓性胆囊炎中转开腹。胆囊中至重度粘连者41例（73％）。胆囊白胆汁或无胆汁23例（41％）。胆囊床小胆管损伤2例（4％）、胆囊床肝组织损伤出血15例（27％），术中胆囊破溃19例（34％）。无大胆管损伤及大出血并发症。术后住院（3．6±1．5）d。随访6～12个月，平均11个月，症状消失，无并发症发生。结论巨大胆囊结石LC的难点是由于胆囊长期的慢性炎症、机化所致的胆囊剥离困难以及由此引起的胆囊床的肝组织损伤和胆囊床小胆管损伤。仔细剥离和保留部分胆囊壁是恰当的处理对策。

Objective To explore difficulties and countermeasures of laparoscopic cholecystectomy （LC） for treating huge gallstones. Methods Fifty-six cases of huge gallstones with a diameter of 2.0 - 5.3 cm （ 3.4 ± 0.6 cm） were reviewed in respect of their clinical features and operative difficulties and countermeasures during laparoscopic cholecystectomy. Results The laparoscopic cholecystectomy was completed smoothly in 54 cases, with an operation time of 30 -130 min （94.3 ± 40.7 min）. Conversions to open surgery were required in 2 cases because of acute suppurative cholecystitis. Moderate-to-severe adhesion was found in 41 cases （73%）. White bile or absence of bile secretion was found in 23 cases （41%）. There were 2 cases （4%） of small bile duct injuries in the gallbladder bed, 15 cases （27%） of liver tissue injures in the gallbladder bed, and 19 cases （34%） of intraoperative gallbladder leakage. No major bile duct injury or massive hemorrhage occurred. The postoperative hospitalization time was 3.6 ± 1.5 days. Follow-up observations for 6 - 12 months （ mean, 11 months） found that the symptoms disappeared and no complications were noted. Conclusions The difficulties during LC for huge gallstones lie in the thickening of the gallbladder wall that causes injuries of the liver tissue and small bile ducts in the gallbladder bed. Careful dissection and reservation of part of the gallbladder wall are effective methods to lower the incidence of complications.