Hunter J G
Department of Surgery, University of Utah School of Medicine, Salt Lake City 84132.
Am J Surg. 1991 Jul;162(1):71-6. doi: 10.1016/0002-9610(91)90207-t.
Common bile duct (CBD) injury during laparoscopic cholecystectomy appears to have a higher incidence than during open cholecystectomy. This may be a function of inadequate instruction, inadequate caution, or inexperience, or may represent an inherent flaw in laparoscopic exposure. The aim of this study was to identify several steps in laparoscopic exposure of the gallbladder, cystic duct, and Calot's triangle to minimize the risk of surgical disorientation and CBD injury. A review of the first 180 laparoscopic cholecystectomies from the author's series was performed. Maneuvers that provided optimal exposure of the critical anatomy were culled from the video record. These maneuvers were (1) routine use of a 30 degree forward oblique viewing telescope, (2) firm cephalic traction on the fundus of the gallbladder to reduce redundancy in the infundibulum of the gallbladder and best expose the cystic duct, (3) lateral traction on the infundibulum of the gallbladder to place the cystic duct perpendicular to the CBD, (4) dissection of the cystic duct at the infundibulum of the gallbladder, and (5) routine fluoroscopic cholangiography. If these steps do not provide the surgeon with comfortable anatomic orientation, the procedure should be converted to open cholecystectomy.
腹腔镜胆囊切除术中胆总管（CBD）损伤的发生率似乎高于开腹胆囊切除术。这可能是由于指导不足、不够谨慎或缺乏经验，也可能是腹腔镜暴露存在固有缺陷。本研究的目的是确定腹腔镜暴露胆囊、胆囊管和胆囊三角的几个步骤，以尽量降低手术迷失方向和CBD损伤的风险。对作者系列中的前180例腹腔镜胆囊切除术进行了回顾。从视频记录中挑选出能提供关键解剖结构最佳暴露的操作。这些操作包括：（1）常规使用30度前斜视角望远镜；（2）对胆囊底部进行牢固的头侧牵引，以减少胆囊漏斗部的冗余并最佳暴露胆囊管；（3）对胆囊漏斗部进行侧向牵引，使胆囊管与CBD垂直；（4）在胆囊漏斗部解剖胆囊管；（5）常规荧光透视胆管造影。如果这些步骤不能为外科医生提供舒适的解剖定位，则应将手术转为开腹胆囊切除术。
