Philips J A E, Lawes D A, Cook A J, Arulampalam T H, Zaborsky A, Menzies D, Motson R W
ICENI Centre, Colchester General Hospital, Colchester, CO4 5JL, UK.
Surg Endosc. 2008 Jul;22(7):1697-700. doi: 10.1007/s00464-007-9699-5. Epub 2007 Dec 11.
The risk of damage to the bile duct and structures in the hilum of the liver is significant when Calot's triangle cannot be safely dissected during laparoscopic cholecystectomy, and conversion to an open procedure often is performed. This is more common during emergency surgery, but may not render the procedure any easier. Traditionally, open subtotal cholecystectomy was performed, but with the advent of laparoscopic surgery, this has fallen from favor. The authors report their experience using laparoscopic subtotal cholecystectomy to avoid bile duct injury and conversion in difficult cases.
Laparoscopic subtotal cholecystectomy, performed when the cystic duct cannot be identified safely, consists of resecting the anterior wall of the gallbladder, removing all stones, and placing a large drain into Hartmann's pouch. The notes for all patients who underwent a laparoscopic subtotal cholecystectomy between 1 September 2001 and 31 December 2004 were retrospectively analyzed.
Subtotal cholecystectomy was performed in 26 cases including 13 emergency and 13 elective procedures. The median age of the patients (15 women and 11 men) was 68 years (range, 36-86 years). The indications were severe fibrosis in 16 cases, inflammatory mass or empyema in 8 cases, and gangrenous gallbladder or perforation in 2 cases. The median postoperative inpatient stay was 5 days (range, 2-26 days). Five patients underwent postoperative endoscopic retrograde cholangiopancreatography: four for persistent biliary leak and one for a retained common bile duct stone. One patient required laparotomy for subphrenic abscess, and one patient (American Society of Anesthesiology [ASA] grade 4, presenting with biliary peritonitis) died 2 days postoperatively. One patient required a subsequent completion laparoscopic cholecystectomy for a retained gallstone. One patient had a chest infection, and two patients experienced port-site hernias.
Laparoscopic subtotal cholecystectomy is a viable procedure during cholecystectomy in which Calot's triangle cannot be dissected. It averts the need for a laparotomy.
在腹腔镜胆囊切除术中，如果无法安全地解剖胆囊三角，肝门部胆管及结构受损的风险很大，通常会转为开腹手术。这在急诊手术中更为常见，但可能并不会使手术变得更容易。传统上采用开腹胆囊次全切除术，但随着腹腔镜手术的出现，这种方法已不再受欢迎。作者报告了他们在困难病例中使用腹腔镜胆囊次全切除术避免胆管损伤和中转开腹的经验。
当无法安全识别胆囊管时，进行腹腔镜胆囊次全切除术，包括切除胆囊前壁、取出所有结石，并在Hartmann袋内放置一根大引流管。对2001年9月1日至2004年12月31日期间接受腹腔镜胆囊次全切除术的所有患者的病历进行回顾性分析。
共进行了26例胆囊次全切除术，其中急诊手术13例，择期手术13例。患者（15名女性和11名男性）的中位年龄为68岁（范围36 - 86岁）。手术指征为重度纤维化16例、炎性肿块或积脓8例、坏疽性胆囊炎或穿孔2例。术后中位住院时间为5天（范围2 - 26天）。5例患者术后接受了内镜逆行胰胆管造影术：4例因持续性胆漏，1例因胆总管残留结石。1例患者因膈下脓肿需要开腹手术，1例患者（美国麻醉医师协会[ASA] 4级，表现为胆汁性腹膜炎）术后2天死亡。1例患者因残留胆结石需要二期完成腹腔镜胆囊切除术。1例患者发生肺部感染，2例患者出现切口疝。
腹腔镜胆囊次全切除术是在无法解剖胆囊三角的胆囊切除术中一种可行的手术方法。它避免了开腹手术的需要。
