坏疽、重症胆囊炎腹腔镜两孔胆囊切除策略

Strategies for the Operation of Cholecystectomy of Suppurative and Serious Cholecystitis with Laparoscope Through Two Operation Holes

目的：在胆囊病变急性发作致胆囊坏疽、重症胆囊炎情况下，探讨腹腔镜两操作孔下胆囊切除的处理策略。方法：四步法进行坏疽、重症胆囊切除：先行胆囊与周围粘连的分离，了解Calot三角关系或重要内容行程；再行胆囊减压，抽吸全部液体性内容；近哈氏袋切开胆囊管周浆膜，用吸引器刮吸胆囊管，致胆囊管和胆囊动脉显露；最后近胆囊壁快速电切分离胆囊床，纱布填压胆囊床及止血。结果：35例患者均成功在两操作孔下完成胆囊切除手术，有5例行胆道造影术，3例行腹腔镜联合胆道镜胆总管切开取石术，术中出血30-650 mL，时间50-130 min。结论：急性坏疽、重症胆囊炎行腹腔胆囊切除手术具有操作难度，表现为胆囊高度充血水肿、肿大积液、易出血和解剖不清，与普通LC术方式上有异常；因重要解剖胆囊管只是轻中度炎症感染，故对有经验的腹腔镜操作者，尽管胆囊存在重症感染，仍可行两操作孔腹腔镜胆囊切除术。

Objective： An acute attack of cholecystopathy can cause gallbladder abscess or gangrene, to discusses the strategies for treatment of inflammatory infection of severe acute cholecystopathy through two operation holes.Method： There were four steps in LC. The first step was to separate cholecyst from the adhesions around to have a preliminary understanding of Calot triangle or important content, when the cholecyst was under tension. Then, an artificial window to be opened in the cholecyst wall, and a pressure-relief aspirator to be placed into it to aspirate all the liquid content. The third step was to cut the serosa of the cystic duct near the Hartmann’s pouch, and to use an aspirator to aspirate the cystic duct until the cystic duct and the cystic artery reveal. The fourth step was to separate the cholecyst bed by electrotomy near the cholecyst wall quickly, and to press immediately the cholecyst bed with gauze. The last step was to stop bleeding from top to bottom. Result： All 35 cases of cholecystectomy through two holes were successful. 5 cases were under cholangiography. 3 cases were operated together with Choledochoscope Choledocholithotomy. During the operation, bleeding was 30-650 mL, time was about 50-130 minutes. Conclusion： The operation of cholecystectomy of suppurative and serious cholecystitis is different from normal LC in the aspects of method and program, in expression of high swelling, lard-bucket, esay bleeding, blurring of anatomy. The inflammatory infection of cystic duct is moderate. Although it may cause severe infection, for an experienced laparoscopic operator, cholecystectomy with laparoscope can be used.