不解剖胆囊三角并保留部分胆囊壁的腹腔镜胆囊切除术

Laparoscopic cholecystectomy with undissected calot triangle and remained partial gall bladder wall

目的：探讨不解剖胆囊三角并保留部分胆囊壁的腹腔镜胆囊切除术（LC）治疗慢性胆囊炎/胆囊结石并胆囊壁高度纤维化患者的疗效。方法89例慢性胆囊炎/胆囊结石并胆囊壁高度纤维化的患者均接受四孔法LC，均采用逆行法切除胆囊，术中不解剖Calot三角并保留背侧部分胆囊壁。分析手术疗效。结果89例中78例（87.6％）顺利完成手术，手术时间30～90 min、中位时间45 min，出血量20～50 ml、中位出血量30 ml，术后住院时间4～7 d、中位时间5 d。7例因解剖不清而于术中在超声辅助下完成手术；3例因黏连致密而中转开腹；1例术中误伤（横断）胆总管，经中转开腹行胆总管端端吻合和T管引流术。在仅接受LC的85例患者中，3例术后发生轻微局限性胆漏，经持续负压引流而治愈；3例出现一过性轻微腹泻，术后1～3个月症状自行消失；其余患者无发生其他并发症。所有患者均治愈。结论不解剖胆囊三角并保留部分胆囊壁的LC能有效治疗慢性胆囊炎/胆囊结石并胆囊壁高度纤维化患者，但如因黏连致密确实无法解剖，则宜果断中转开腹以避免发生严重手术事故。

Objective To evaluate the curative effect of laparoscopic cholecystectomy （LC）with undissected calot triangle and remained partial gall bladder wall in patients with chronic cholecystitis/cholecys-tolithiasis combined with highly fibrotic gall bladder wall. Methods Eighty-nine cases of chronic cholecystitis/cholecystolithiasis combined with highly fibrotic gall bladder wall received LC of four hole method. During operation,retrograde method was used,with undissected calot triangles and remained partial gall bladder walls. The effect of this surgical method was analyzed. Results Seventy-eight cases （87.6%）of all patients underwent the operation successfully. The operating time was 30～90 min,with an average of 45 min. Bleeding amount was 20～50 ml,with an average of 30 ml. The hospitalized time was 4～7 d,with an average of 5 d.Seven cases with opaque operative field underwent LC with ultrasound assistance successfully. Three cases were converted to open cholecystectomy because of tissue adhesion. One case with iatrogenic common bile duct injury converted to open cholecystectomy,and then received bile total pipe anastomosis and Ttube drainage. Three of 85 cases only received LC with mild biliary fistula and were cured by the continuous negative pressure drain-age. 3 cases with transient mild diarrhea were resolved spontaneously in 1 to 3 months after operation. All pa-tients were cured without other surgical complications. Conclusions LC with undissected calot triangle and remained partial gall bladder wall can effectively treat patients with chronic cholecystitis/cholecystolithiasis combined with highly fibrotic gall bladder wall,but open cholecystectomy should be considered if there are serious tissue adhesions.