术前超声对腹腔镜胆囊切除术难度的预测

Preoperative sonography in predicting technical difficulties for p atients undergoing laparoscopic cholecystectomy

目的 评估 术 前腹部超声对腹腔镜胆囊切除术难度预测的价值。方法 对连续３９４ 例腹腔镜胆囊切除手术的难度和术前腹部超声进行前瞻性临床研究。术前超声检查包括胆囊 壁厚度、胆囊周围有无积液、胆囊大小、胆总管直径和胆囊结石。腹腔镜胆囊切除术的难易 程度是根据中转剖腹手术病例在腹腔镜下解剖胆囊三角和／或剥离胆囊床的最短时间为标准 来划分。结果 术前超声对胆囊结石诊断正确率为９９．７％。１６例（４． １％）中转剖腹前腹腔镜下解剖胆囊三角和／或剥离胆囊床的最短时间为２９．３ ｍｉｎ。超声检查 胆囊壁增厚（＞３ ｍｍ）１１３例中有９９例（８７．６％）是ＬＣ手术困难的，而胆囊壁小于或等于３ ｍｍ的２ ８１例中只有５２例（１８．５％）为ＬＣ手术困难的，两者差异有显著性（Ｐ＜０．０５）；所有胆囊周 围积液均为ＬＣ手术困难，其中有７５％还中转剖腹手术；１７例胆囊积液中有１６例为ＬＣ手术困难 的（９４．１％），２０例萎缩性胆囊炎中有１８例（９０％）在ＬＣ手术遇到了困难。结论 术前超声检查中胆囊壁增厚是预测ＬＣ手术困难较精确的指标，而胆囊周围积液、 胆囊积液、胆囊萎缩对预测ＬＣ手术困难都具有较高的特异性和阳性预测值。

Objective To assess the value of abdominal so nography in predicting intraoperative technical difficulties for patients underg oing laparoscopic cholecystectomy (LC).Methods 394 consecutiv e patients were included in this prospective clinical study. Gallbladder wall, p ericholecystic fluid, size, stone or polpy, and diameter of common bile duct wer e emphasized in preoperative sonography. The minimal time required to dissect l aparoscopically gallbladder triangle and bed of patients before conversion to op en cholecystectomy (OC) was judged as criteria of technical difficulty of LC.Results The accuracy of preoperative sonography for cholecysto lithiasis was 99.7%. 16 patients (4.1%) were converted to OC. The minimal time r equired for laparoscopic dissection of Calot triangle and gallbladder bed before OC was 29.3min which was judged as demonstrating technical difficulty of LC. 99 of 113 patients (87.6%) with thick gallbladder wall (>3 mm) and 52 of 281 patie nts (18.5%) without thick gallbladder wall (=<3 mm) had technical difficulties i n LC procedures respectively (P<0.05). All of patients with pericholecystic fluid had technical difficulties of LC including 75% of them converting to OC. A lso, 16 of 17 (94.1%) empyema gallbladders and 18 of 20 (90%) shrunken gallbladd ers were performed in LC with difficulty.Conclusions On p reoperative sonography, gallbladder wall thickening is the accurate indicator of technical difficulties during LC. Pericholecystic fluid and shrunken or empyema gallbladders are very meaningful in specificity and positive predictive value o f predicting technical difficulties in LC.