腹腔镜胆囊切除术治疗急性胆囊炎并结石（附528例报告）

Laparoscopic Cholecystectomy for Acute Cholecystitis Complicated with Gallstones

目的：探讨腹腔镜胆囊切除术（Laparoscopic cholecystectomy，LC）治疗急性胆囊炎并结石的疗效。方法：2005年6月-2009年12月对528例急性胆囊炎并结石施行四孔法LC，腹腔内压力控制在11～13mmHg，对一些年老体弱的患者，气腹压力控制在10ramHg。若术中探查发现胆囊三角水肿明显，解剖困难，则逆行切除胆囊，若术中发现胆囊管内结石嵌顿，则尽量将结石挤入胆囊后切除胆囊，为防止胆囊管内结石进入胆总管，术中经胆囊管行胆道造影，排除胆管结石。结果：510例LC成功；18例中转开腹；术中出血及解剖困难10例，术中发现胆管结石8例。1例术后出血，经二次手术止血后康复出院，3例术后2—4d发生胆漏，引流量少。每天30—70ml，采取保守治疗（禁食静脉补液和静脉用抗生素）后治愈。528例术后随防1—12个月，平均6个月，未出现术后并发症。结论：LC治疗息性胆囊炎并结石可行且有效，但应选择恰当的手术时机，解剖胆囊三角显露胆囊管是手术的关键，当腹腔镜手术遇到困难时，应适时中转开腹手术。

Objective To investigate the efficacy of laparoscopic Cholecystectomy （LC） for patients with acute cholecystitis complicated with gallstones. Methods From June 2005 to December 2009, 528 patients with acute eholecystitis complicated with gallstones underwent lc in our hospital. Four trocar were used in the operation. During the procedure, intraperitioned pressure was controlled at 11 to 13 mm Hg （10 ram Hg for elderly paOents）. Retrograde cholecystectomy was performed on the patients with difficult anatomy caused by edema of the cystic triangle. For cases with calculi incarcerated in the cystic duct ,the lc was performed after the stones were removed into the cyst （cholangiography was performed to exclude bile duct calculi）. Results of the 528 cases , Lc was completed successfully in 510 patients, the other 18 cases were converted into open surgery because of massive hemorrhage and difficult anatomy （10 cases ） or bile duct calculi（8 cases）. After the Lc ,one patient received a second surgery because of postoperative hemorrhage ; three patients developed bile leakage （occurred at 2--4： days after the Le with 30--70 ml of drainage） and were cured by conservative therapy ineluding fasting, intravenous nutition and auti-biotie therapy. This series were followed up for 1 to 12 months （mean 6 months） No post--operative eomplitions were noticed during the period. Conclusions Le is a safe and effective for patients with acute choleeystitis complicated with gallstones. Controlling the operation opportunity properly and dissecting the ealot＇s triangle area carefully to expose the cystic duct are the key steps during the operation. Convertion to open surgery is necessary in some difficult situation.