腹腔镜肝镰状韧带入路胆囊切除巧避右上腹瘢痕粘连

Laparoscopic cholecystectomy from broad hepatic ligament fencing with cicatricial adhesion of right upper quadrant cleverly

目的腹腔镜脐入路下右上腹瘢痕粘连在分离并建立手术空间失败后,探讨改从左上腹经肝镰状韧带入路行困难型腹腔镜胆囊切除的可能性和实用性。方法 2001年5月～2010年9月该科有7例患者(有右上腹手术史及腹膜炎史)行腹腔镜胆囊切除术,因术中发现右上腹瘢痕粘连,在分离失败后,改从肝镰状韧带入路后发现:瘢痕粘连区域外呈轻中度以下粘连,肝脏与膈面常无粘连或仅为容易分离的膜性粘连,沿肝脏脏面向下解剖而进行腹腔镜胆囊探查及切除术。结果 7例有右上腹瘢痕粘连的病例,经肝镰状韧带入路巧妙避开难以分离的粘连面,均成功进行腹腔镜胆囊探查及切除术,有2例完成腹腔镜下经胆囊管行胆道造影术。结论有右上腹手术史及腹膜炎史者出现右上腹瘢痕粘连时,对腔镜镜经验丰富者不应列为腹腔镜胆囊切除术的禁忌证;瘢痕粘连区域外呈轻中度以下可分离的粘连,使新路径手术避开了瘢痕粘连障碍;该路径对手术者视向及站位无明显改变,探索出腹腔镜胆囊切除术的新路径。

【Objective】To explore the possibility and practicality of difficulty resecting the gallbladder with a laparoscope from broad hepatic ligament fencing with cicatricial adhesion of right upper quadrant after failing to separate the right upper quadrant cicatricial adhesion and create the space for operation from fovea umbilicalis.【Methods】From May 2001 to September, 2010, seven patients （with the right upper abdomen surgeries or peritonitis history ） received the operations of resecting the gallbladder with a laparoscope, in which cicatricial adhesion of the right upper quadrant was discovered. We started from broad hepatic ligament after failing to separate the adhesion and create the space for operation. 【Results】Seven patients with cicatricial adhesion of the right upper quadrant received the operation of resecting the gallbladder with a laparoscope from broad hepatic ligament fencing with right upper quadrant adhesion. Two patients received cholangiography through cystic duct with the help of laparoscope. 【Conclusion】For patients with right upper abdomen surgeries or peritonitis history, when there is cicatricial adhesion of right upper abdomen ,these shouldn＇t be classified as contraindication of resecting the gallbladder with laparoscope for operator of laparoscopic abundant experience. Because of little adhesion of left upper abdomen, it is possible to resect the gallbladder with a laparoscope from broad hepatic ligament fencing with right upper quadrantadhesion. This can help patients be free from the pain of opening abdomen. This new path does not change the standing position and visual direction obviously, and it has been founded from broad hepatic ligament.