Mahmud S, Masaud M, Canna K, Nassar A H M
Upper Gastrointestinal and Laparoscopic Service, Department of Surgery, Vale of Leven District Hospital, Dunbartonshire, Scotland, G83 OUA, UK.
Surg Endosc. 2002 Apr;16(4):581-4. doi: 10.1007/s00464-001-9094-6. Epub 2001 Dec 17.
Fundus-first dissection (FFD) is an established technique to deal with difficult open cholecystectomies. Although the indications for such an approach are similar for laparoscopic cholecystectomy (LC), FFD is not widely practiced because of difficulties that arise with liver retraction, the dissection of dense adhesions, or obscured cystic pedicles, often necessitating conversion to an open procedure.
The aim of this study was to evaluate the indications for FFD and the technical aspects of the procedure in cases with a difficult cystic pedicle. Prospectively collected data and video recordings of cases of fundus-first laparoscopic cholecystectomy (FFLC) were analyzed. The great majority were difficult cases, so we also reviewed the safety aspects of this approach and assessed its effect on the conversion rate.
FFLC was resorted to in 35 cases (5%) of 710 consecutive LCs with difficulty grade II (two cases), III (13 cases), or IV (20 cases). There were 16 male patients (46% vs 9% males in the whole), and the mean age was 56 years (ranges, 28-87). The reasons for FFD were dense adhesions preventing the exposure of the cystic pedicle in 14 cases, large Hartmann's pouch stones in 10 cases, short dilated cystic ducts in six cases, and Mirizzi syndrome in three cases. Two cases had contracted "burn-out" gallbladders. Intraoperative cholangiography (IOC) was possible in 24 patients, failed in 10 (29%), and was not attemped in one. Seven patients had bile duct stones and required bile duct exploration. FFLC was completed in 31 patients, 28 of whom were seriously considered for conversion prior to commencing FFD. Conversion was still necessary after trial FFD in four cases (11%) two with Mirizzi abnormalities, one with bile duct stones, and one with dense adhesions. The mean operative time was 125 min, (range, 50-230). There were no operative or technique-related complications.
FFLC is feasible and is a safe option for cases with a difficult cystic pedicle. Its use reduced the conversion rate of the series from a potential 5.2% to 1.2%, However, subtotal cholecystectomy or conversion must not be delayed if, after the neck of the gallbladder is reached the anatomy is still unclear.
胆囊底优先解剖（FFD）是处理困难开放性胆囊切除术的一种成熟技术。尽管这种方法在腹腔镜胆囊切除术（LC）中的适应证相似，但由于肝脏牵拉、致密粘连分离或胆囊蒂模糊不清等困难，FFD并未广泛应用，常需转为开放手术。
本研究旨在评估FFD在胆囊蒂困难病例中的适应证及手术技术要点。对前瞻性收集的胆囊底优先腹腔镜胆囊切除术（FFLC）病例的数据和视频记录进行分析。绝大多数为困难病例，因此我们还回顾了该方法的安全性，并评估其对中转率的影响。
在710例连续LC中，35例（5%）因困难程度为II级（2例）、III级（13例）或IV级（20例）而采用FFLC。有16例男性患者（占全部患者的46%，而全部患者中男性占9%），平均年龄为56岁（范围28 - 87岁）。FFD的原因包括14例因致密粘连妨碍胆囊蒂暴露、10例因巨大Hartmann袋结石、6例因胆囊管短且扩张、3例因Mirizzi综合征。2例为萎缩性“耗竭”胆囊。24例患者可行术中胆管造影（IOC），10例失败（29%），1例未尝试。7例患者有胆管结石，需要胆管探查。31例患者完成了FFLC，其中28例在开始FFD前曾被认真考虑中转。在试行FFD后，仍有4例（11%）需要中转，2例为Mirizzi异常，1例为胆管结石，1例为致密粘连。平均手术时间为125分钟（范围50 - 230分钟）。无手术或技术相关并发症。
FFLC是可行的，对于胆囊蒂困难的病例是一种安全的选择。其应用使该系列病例的中转率从潜在的5.2%降至1.2%。然而，如果到达胆囊颈部后解剖结构仍不清楚，不应延迟行胆囊次全切除术或中转手术。
