Memon M A, Deeik R K, Maffi T R, Fitzgibbons R J
Department of Surgery, Queens Medical Center, Nottingham, UK.
Surg Endosc. 1999 Sep;13(9):848-57. doi: 10.1007/s004649901118.
Gallbladder perforation during laparoscopic cholecystectomy (LC) with spillage of bile and gallstones occurs in a substantial number of patients (up to 40%). Most surgeons believe that free intraperitoneal stones are not a justification for conversion to laparotomy even if a large number of stones are left in situ. There are, however, a number of reports demonstrating that, on occasion, these unretrieved gallstones may cause infection or abscess, inflammation, fibrosis, adhesions, cutaneous sinuses, small bowel obstruction, or generalized septicemia. The aim of this study was to determine the outcome of unretrieved gallstones in the peritoneal cavity after gallbladder perforation during LC.
In a 7-year period between 1989 and 1996, prospective data were maintained on 856 patients who underwent LCs by a single surgeon (R. J.F.). Of the 856 patients, 165 (16%) had gallbladder perforations resulting in lost gallstones in the peritoneal cavity. A concerted attempt was made to remove the lost stones using a variety of extraction devices. Of these 165 patients, 106 (64%) were available for follow-up through mail (76%) and by telephone (24%). The mean age of these patients was 64.9 years (range, 18 to 98 years), and the mean follow-up was 44.8 months (range 4.9 to 92.3 months).
Of the 106 patients with unretrieved gallstones, we identified four patients with short-term complications and one patient with a long-term complication. The first patient with a short-term complication had pyrexia for 10 days postoperatively. Diagnostic evaluation, which included computed tomography (CT) scan, failed to reveal any abnormality. The patient was treated conservatively with a course of oral antibiotics. In the second patient, cellulitis developed at a drain site after its removal, which resolved with oral antibiotics. The third patient acquired an umbilical wound abscess, which drained spontaneously, requiring no treatment. A sterile subphrenic collection developed in the fourth patient 1 month postoperatively, which was treated with percutaneous drainage under CT guidance. The only long-term complication was spontaneous erosion of a gallstone from the back of a patient with a questionable history of inflammatory bowel disease 8 months postoperatively. All of the patients made complete recoveries.
In most patients, unretrieved gallstones are of no consequence, but complications occur occasionally. It is therefore advisable to retrieve as many gallstones as possible during LC short of converting to a laparotomy.
在腹腔镜胆囊切除术（LC）过程中，胆囊穿孔并伴有胆汁和胆结石溢出的情况在相当一部分患者中出现（高达40%）。大多数外科医生认为，即使腹腔内遗留大量结石，腹腔内存在游离结石也并非转为开腹手术的理由。然而，有许多报告表明，这些未取出的胆结石有时可能会导致感染或脓肿、炎症、纤维化、粘连、皮肤窦道、小肠梗阻或全身性败血症。本研究的目的是确定LC期间胆囊穿孔后腹腔内未取出胆结石的转归情况。
在1989年至1996年的7年期间，对由一位外科医生（R.J.F.）实施LC的856例患者进行了前瞻性数据记录。在这856例患者中，165例（16%）发生了胆囊穿孔，导致腹腔内有结石遗留。我们协同努力使用各种取出器械取出遗留的结石。在这165例患者中，106例（64%）可通过邮件（76%）和电话（24%）进行随访。这些患者的平均年龄为64.9岁（范围18至98岁），平均随访时间为44.8个月（范围4.9至92.3个月）。
在106例有未取出胆结石的患者中，我们发现4例有短期并发症，1例有长期并发症。第一例有短期并发症的患者术后发热10天。包括计算机断层扫描（CT）在内的诊断评估未发现任何异常。该患者接受了一个疗程的口服抗生素保守治疗。第二例患者在引流管拔除后引流部位发生蜂窝织炎，口服抗生素后痊愈。第三例患者出现脐部伤口脓肿，自行引流，无需治疗。第四例患者术后1个月出现无菌性膈下积液，在CT引导下进行了经皮引流治疗。唯一的长期并发症是一名有炎性肠病可疑病史的患者术后8个月胆结石自背部自发侵蚀。所有患者均完全康复。
在大多数患者中，未取出的胆结石并无大碍，但偶尔会发生并发症。因此，在LC期间，在不转为开腹手术的前提下，建议尽可能多地取出胆结石。
