结石嵌顿坏疽性胆囊炎腹腔镜手术处理与并发症预防(附36例报告)

Operational Management and Complication Prevention of Laparoscopic Cholecystectomy for Gangrenous Cholecystitis Caused by Incarcerated Gallstones:Report of 36 Cases

目的：探讨结石嵌顿坏疽性胆囊炎腹腔镜胆囊切除术的技巧与并发症预防。方法2009年6月～2014年6月急诊LC治疗结石嵌顿坏疽性胆囊炎36例，胆囊底部穿刺减压以显露胆囊壶腹，减压后显露困难者需要切开胆囊壁取出结石，紧贴壶腹部采用刮吸钝性分离胆囊前和后三角区，显露胆囊管，近胆囊侧夹闭、离断胆囊管；结石嵌顿致胆囊管径较大夹闭困难，采用4号可吸收线缝扎或胆囊颈部胆囊黏膜残留。结果 LC 35例，中转开腹手术1例。手术时间45～150 min，平均55 min。术中出血量50～250 ml，平均80 ml。住院时间3～10 d，平均4．5 d。1例术后胆漏，保守治愈。无腹腔出血、感染等并发症。31例随访6～18个月，平均11个月，无腹痛、黄疸、胆管狭窄和继发性胆管结石等发生。结论重视术前影像学检查，术中精细的操作和合理处理是LC治疗结石嵌顿坏疽性胆囊炎的关键。

Objective To explore the operational management and complication prevention of laparoscopic cholecystectomy for gangrenous cholecystitis caused by incarcerated gallstones . Methods Laparoscopic cholecystectomy was urgently performed in 36 patients with gangrenous cholecystitis caused by incarcerated gallstones .The puncture was performed to decompress the gallbladder at the bottom of the gallbladder in order to reveal the gallbladder ampulla .The gallbladder wall was opened to take out stones when the gallbladder ampulla could not be revealed after decompression .The front and rear gallbladder triangles were bluntly dissected adjacent to the gallbladder ampulla to reveal the cystic duct .Then the cystic duct was clipped and cut off near the gallbladder ampulla .The cystic duct was closed with 4-0 absorbed stitches or left open with residual gallbladder mucosa in the gallbladder neck . Results Laparoscopic cholecystectomy was performed in 35 patients, with a conversion to open cholecystectomy performed in 1 patient.The operation time was 45-150 min, with a mean of 55 min.The mean intraoperative blood loss was 80 ml （range, 50-250 ml）.The hospital stay was 3 -10 d, with a mean of 4.5 d.The bile leakage occurred in 1 patient after operation , which was cured with conservative treatment .There were no complications such as abdominal bleeding or infection in all the patients .A total of 31 patients were followed up for 6-18 months （ mean, 11 months ） .No abdominal pain , jaundice , bile duct stricture , or secondary bile duct calculus occurred in all the patients . Conclusion It is crucial in laparoscopic cholecystectomy for gangrenous cholecystitis caused by incarcerated gallstones that preoperative imaging examination , fine intraoperative performance , and rational management are emphasized.