腹腔镜胆囊切除术术中操作困难的处理体会

Treatment experience of difficult laparoscopic cholecystectomy

目的：探讨腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）术中操作困难的应急处理措施及手术技巧。方法：回顾分析2002年8月至2011年10月106例患者于LC术中发生操作困难的临床资料。结果：101例顺利完成LC：其中胆囊动脉变异9例,局部或腹腔粘连23例,局部脂肪堆积13例,肝叶肥大3例,胆囊管或颈部结石嵌顿11例,Ⅰ型Mirizzi综合征1例,胆囊萎缩11例,肝内胆囊8例,胆道变异2例,巨大胆囊结石8例,充满型胆囊结石7例,5例患者胆囊充血水肿、化脓坏疽、胆囊壁明显增厚≥0.6 cm。1例行腹腔镜胆囊造瘘术;4例中转开腹,其中1例有上腹部手术史,开放法建立气腹失败;1例胆囊床渗血镜下难以止血;2例胆囊及三角区冰冻样改变。手术时间60~240 min,平均（139.5±46.0）min;术中出血量10~200 ml,平均（85.7±49.9）ml。69例放置腹腔引流管,术后引流液多为淡血性,引流量10~80 ml/d,平均（39.4±20.3）ml/d。术后3~7 d拔除引流管,平均（4.75±1.09）d。术后3~11 d痊愈出院,平均（6.15±1.98）d。81例随访3~12个月,平均（6.82±1.95）个月,6例感右上腹部隐痛不适,自行服用消炎利胆片半个月后消失;5例上腹部饱胀不适、4例轻度腹泻,3个月后症状消失。余患者未见不良并发症。结论：对于LC术中操作困难的患者,应稳健处理,切忌慌乱,遵循＂结构细辨明,解剖靠胆囊,分离三结合（顺逆结合、钝锐结合、胆囊前后三角结合）,一宁三勿（宁伤胆,勿伤肠、肝、管）＂的原则,多可顺利施术,胆囊大部切除或中转开腹利于减少术中意外损伤。

Objective： To investigate the emergent management and operative technique of difficult laparoscopic cholecystectomy（ LC）. Methods： The clinical data of 106 patients who underwent difficult LC from Aug. 2002 to Oct. 2011 were retrospectively analyzed. Results： One hundred and one cases of LC were successful,among these cases there were 9 cases of gallbladder artery variation,23 cases of local or abdominal adhesion,13 cases of local accumulation of fat,3 cases of liver lobe hypertrophy,11 cases of calculus incarcerated in cystic duct or neck,1 case of type Ⅰ Mirizzi syndrome,11 cases of gallbladder atrophy,8 cases of gallbladder in liver,2cases of cystic duct variation,8 cases of huge calculus,7 cases of fully filled gallbladder calculus,5 cases of hyperemia,ecpyesis and gangrene of gallbladder and incrassation of gallbladder wall（ ≥0. 6 cm）. 5 cases of LC were not successful： 1 case of laparoscopic fistulization of gallbladder,4 cases were converted to open operation. 1 patient had the abdominal operation history and failed to establish pneumoperitoneum by open method,1 case was difficult in hemostasis of errhysis at gallbladder bed,2 cases of gallbladder triangle area were frozen like change. Operation time was（ 139. 5 ± 46. 0） min（ range,60-240 min）,intraoperative blood loss during operation was（ 85. 7 ± 49. 9） ml（ range,10-200 ml）. Drainage tube was placed in 69 cases,postoperative drainage liquid was light bloody,drainage amount was（ 39. 4 ± 20. 3） ml / d（ range,10-80 ml / d）. The drainage tube was removed in（ 4. 75 ± 1. 09） d（ range,3-7 d） after operation. Postoperative hospital stay was（ 6. 15 ± 1. 98） d（ range,3-11 d）. 81 patients were followed up for（ 6. 82 ± 1. 95） months（ range,3-12 months）,6 cases occurred dull pain at right upper quadrant,and recovered after using xiaoyanlidan tablet for half a month; 5 cases of glutted right upper quadrant,4 cases of light diarrhea disappeared within 3 months. Other patients did not suffer from undesirable complications. Conclusions： For the difficult LC,surgeons should be firm and steady,cannot be hurry and confusious,follow the principle of ＂careful distinguishing the structure,dissection near the gallbladder,sequent-converse combination,sharp and blunt combination,combination of anterior and posterior gallbladder triangle during separation,gallbladder could be damaged,intestine,liver,bile duct must not be damaged＂. With the principle,most operations can be smoothly completed,and subtotal cholecystectomy and con-version to open operation can reduce the unexpected damage.