腹腔镜胆囊切除术中结石落入腹腔的原因分析及处理

REASONS AND TREATMENT OF GALLSTONE RETAINED IN PERITONEAL CAVITY DURING LAPAROSCOPIC CHOLECYSTECTOMY

目的 :探讨LC术中结石落入腹腔造成腹腔结石残留的原因、预防措施及处理方法。方法 :对 1995年 5月～ 2 0 0 1年 5月所施行的 2 40 0例LC术中发生结石落入腹腔的 15 6例进行回顾性分析。结果 :2 40 0例LC中 ,结石落入腹腔 15 6例 ,其发生率约为 6 .5 %。随访 1～ 6年 ,1例病人术后出现轻微腹痛 ,1月后腹痛消失 ;1例术后第 3天出现低热、腹部不适 ,B超发现胆囊窝少量积液 ,有一粒结石残留 ,1周后出院 ,随访 3月仍感腹痛。本组无腹腔感染 ,窦道形成。结论 :胆囊被电凝钩分破或胆囊被有齿抓钳抓破、慢性萎缩性胆囊炎行胆囊大部切除时胆囊管胆囊侧钛夹脱落、自戳孔取出胆囊时胆囊被挤破是结石落入腹腔的原因。LC术中采用各种方法取尽落入腹腔的结石是预防腹腔结石残留的主要措施。LC术中未能全部取出的结石是细小结石或结石碎片 ,不必中转开腹取石 ,术后应密切观察随访。如落入腹腔的结石过大或数量过多 ,腹腔镜下无法找到时 ,应扩大主操作孔至 2～ 3cm ,伸入手指在腹腔镜下寻找结石 。

Objective:To investigate the reasons and administrative ways of spilling gallstone in peritoneal cavity during laparoscopic cholecycstectomy (LC).Methods:Between May 1995 and May 2001,2400 patients were treated with LC.There were 156 cases gallstone dropped into peritoneal cavity during LC.That were retrospectively analysed.Results:In this groups,there were 156 patients with gallstone splillage into abdominal cavity and the incidence was about 6.5%.In these patients,120 cases were gallstone fall into peritoneum because of cutting into the wall of the gallbladder when it is being dissected away from the liver,and 16 cases chronic atrophic cholecysits when dissecting that were gallbladden ruputure,and 12 cases were because of galladder perforation puncture by forceps during enlarging abdominal orifice,and other 8 cases were because of dislodyement side of the clip from the gallbladder side of the cystic duct.Following up 1～6 years,one case,postoperation got stomachacke continue 1 month,another patient feels a little fever and has a pain in the stomach the third day after operation,with B-ultrasonography help,there was a little liquid in the fossa of gallbladden,and leave a piece of gallstone,the patient left the hospital one week later,after three months,the patient still has pain in the stomach.In this group,there were not complications secondary to the stomach.In this group,there were not complications secondary to those spilled stones such as pertieneal cavity infection and fistula form.Conclusions:Gallbladder perforation by puncture during dissection,forceful retration on the gallbladder during dissection resulting in tearing the gallbladder,side of the cystic duct and applying excessive force on the gallbladder during extracting through anterion abdominal orifice are the main reason of spillage gallage gallstones during LC.In order to avoid some complication related to spilled stones during LC,various effort should be made to remove them.However,it is not recommended to perform laparotomy in order to remove all spillage gallstones during LC because most retained stones are harmless to patients.If the gallstones spillage into abdominal cavity are too big or great many,we can't find them with laparoscopy's help.We should widen the main holes to 2～3cm,then with laparoscopy's help again,and we use fingers to take away all gallstones.