腹腔镜胆囊废弃术治疗小体积萎缩性胆囊炎的临床体会

Clinical experience of laparoscopic gallbladder disabled technique for 184 cases with small volume atrophic cholecystitis

目的:探讨腹腔镜胆囊废弃术治疗小体积萎缩性胆囊炎的安全性及临床效果。方法:2007年3月至2018年2月为184例小体积萎缩性胆囊炎患者施行腹腔镜损伤控制性纾困手术,根据胆囊萎缩趋向及位置,分为5种病理情况分类处理胆囊管及胆囊三角:(1)胆囊管、胆囊三角均可分离;(2)胆囊管可分离,胆囊三角闭塞;(3)胆囊管闭塞或消失,胆囊三角可分离;(4)胆囊管与胆囊三角均闭塞消失;(5)胆囊壁与周围脏器严重纤维化粘连甚至形成内瘘。第(1)种情况行传统经典胆囊切除术,其他情况施行纾困治疗的胆囊废弃术,酌情纵向或横向直接剖开胆囊取石,然后决定胆囊壁切除的多寡。合并胆总管结石的患者同期处理。结果:本组均顺利完成腹腔镜手术,未合并胆总管结石的158例患者,86例3孔法完成,72例4孔法完成,无一例中转开腹及发生胆管损伤。术中出血量平均(6.4±4.5)mL,术后发生胆漏2例,持续引流2~4 d自愈。术后平均住院(4.1±1.6)d;合并胆总管结石26例,均4孔法完成手术。结论:取净结石,分类妥善处理胆囊管及胆囊三角,废弃胆囊功能,可安全地完成小体积萎缩性胆囊炎的腹腔镜手术治疗。胆囊废弃术可作为腹腔镜治疗的可选术式。

Objective:To explore security measures and clinical effects of laparoscopic gallbladder disabled technique for the small volume atrophic cholecystitis.Methods:From Mar.2007 to Feb.2018,184 patients with small volume atrophic cholecystitis received damage control surgery.According to the gallbladder atrophic trend and its location,the cystic duct and hepatocystic(HC)triangle were classified into 5 pathological conditions:①the cystic duct and the HC triangle can be free;②the cystic duct is free and the HC triangle is occluded;③the cystic duct is occluded or disappeared,the HC triangle can be separated;④the cystic duct and the HC triangle were occluded or disappeared;⑤severe fibrosis adhesion between the gallbladder wall and the surrounding organs even forms an internal fistula.In most cases,bail-out techniques such as subtotal fenestrated cholecystectomy or subtotal reconstituted cholecystectomy and so on was generally performed.Laparoscopic homochronous operation was used to treat the complicated choledocholithiasis.Results:One hundred and fifty-eight cases of the small volume atrophic cholecystitis were successfully completed laparoscopic operation.Laparoscopic disabled gallbladder without conversion were completed in 86 cases of three-site access,72 cases of four-site access resulted in no cases of bile duct injury.Intraoperative hemorrhage was(6.4±4.5)mL.The drainage lasted for 2-4 d in 2 cases of postoperative bile leakage.The hospitalization time was(4.1±1.6)d.26 cases complicated with choledocholithiasis underwent laparoscopic common bile duct exploration by four-site access successfully.Conclusions:Following procedures:complete removal of calculi,proper management of the cystic duct and the HC triangle,abandon of gallbladder function,can safely complete laparoscopic operation in the treatment of atrophic cholecystitis with small volume.Gallbladder disabled technique could be an alternative of laparoscopic treatment for atrophic cholecystitis.