“困难型“腹腔镜胆囊部分切除的手术技巧与处理原则

Treatment principles and surgical skills in laparoscopic subtotal cholecystectomy for acute cholecystitis

目的探讨急性胆囊炎“困难型”腹腔镜胆囊部分切除（LSC）的手术技巧和处理原则。方法回顾性分析首都医科大学附属北京世纪坛医院2006年1月至2015年12月实施的96例急性胆囊炎困难型LSC临床资料。依照“宁伤胆囊，勿伤其他”的原则分离胆囊周围致密的粘连；应用“胆囊前壁切除，纵行劈开胆囊壶腹和胆囊管，在胆囊内缝合胆囊管开口”的技术处理最危险的胆囊壶腹、胆囊管。结果96例LSC均顺利完成，无中转开腹，无胆管损伤。患者手术时间（108．0±37．0）min，出血量（121．0±62．0）ml，术后腹腔引流（105．0±32．0）ml。术后（3．4±1．2）d拔除引流管。术后住院时间（6．1±2．2）d。外科并发症发生率6．3％。其中出血2例，1例行二次腹腔镜手术止血；另1例保守治疗止血。轻微胆漏3例，通过术中放置的引流管充分引流自愈。1例水肿型胰腺炎，保守治疗痊愈。随访无胆管狭窄、梗黄等远期并发症。结论对于急性胆囊炎LSC手术，依照“宁伤胆囊，勿伤其他”的原则，采用“胆囊前壁切除，纵行劈开胆囊壶腹和胆囊管，在胆囊内缝合胆囊管开口”的技术，可以避免副损伤，手术安全性高。

Objective To study the treatment principles and surgical skills in laparoscopic subtotal cholecystectomy （LSC） for acute cholecystitis. Methods We retrospectively analyzed the clinical data of patients who underwent LSC for acute cholecystitis from Jan. 2006 to Dec. 2015 at the Beijing Shijitan Hospital, Capital Medical University. We dissected any serious pericholecystic adhesions according to the principle that ＂It is better that the gallbladder rather than other tissue is injured＂, and the technique that ＂After the gallbladder anterior wall is excised, the gallbladder ampulla and duct are split along the longitudinal direction of the cholecystic duct, then the opened cholecystic duct is sutured inside the gallbladder＂. Results LSC was completed successfully in 96 patients. There were no conversion to open surgery, and no bile duct injury. The mean surgery time was （108.0 ±37.0） min, the mean blood loss was （121.0±62.0） ml, the mean peritoneal drainage was （ 105.0 ± 32. 0） ml. The drainage tube was removed at a mean of （ 3.4 ± 1.2） d after surgery. The mean hospitalization time after surgery was （6.1 ± 2.2） d. Surgical complications occurred in 2 patients with bleeding after surgery. One patient underwent laparoscopic exploration to stop bleeding. Another patient underwent conservative treatment and the bleeding stopped spontaneously. There were 3 patients who had mild bile leakage. All these patients recovered well after drainage. No patient deve- loped bile duct stenosis or obstructive jaundice on follow-up. Conclusions LSC for acute cholecystitis was safe. Bile duct injuries could be avoided if we follow the principle of ＂It is better that the gallbladder rather than other tissue is injured＂ and the technique of ＂ After the gallbladder anterior wall is excised, the gall-bladder ampulla and duct are split along the longitudinal direction of the gallbladder, then the opened chole- cystic duct is sutured inside the gallbladder＂.