Kelly Michael D
Department of Upper GI Surgery, Frenchay Hospital, Bristol, UK.
BMC Surg. 2009 Dec 11;9:19. doi: 10.1186/1471-2482-9-19.
Retrograde ("fundus first") dissection is frequently used in open cholecystectomy and although feasible in laparoscopic cholecystectomy (LC) it has not been widely practiced. LC is most simply carried out using antegrade dissection with a grasper to provide cephalad fundic traction. A series is presented to investigate the place of retrograde dissection in the hands of an experienced laparoscopic surgeon using modern instrumentation.
A prospective record of all LCs carried out by an experienced laparoscopic surgeon following his appointment in Bristol in 2004 was examined. Retrograde dissection was resorted to when difficulties were encountered with exposure and/or dissection of Calot's triangle.
1041 LCs were carried out including 148 (14%) emergency operations and 131 (13%) associated bile duct explorations. There were no bile duct injuries although conversion to open operation was required in six patients (0.6%). Retrograde LC was attempted successfully in 11 patients (1.1%). The age ranged from 28 to 80 years (mean 61) and there were 7 males. Indications were; fibrous, contracted gallbladder 7, Mirizzi syndrome 2 and severe kyphosis 2. Operative photographs are included to show the type of case where it was needed and the technique used. Postoperative stay was 1/2 to 5 days (mean 2.2) with no delayed sequelae on followup. Histopathology showed; chronic cholecystitis 7, xanthogranulomatous cholecystitis 3 and acute necrotising cholecystitis 1.
In this series, retrograde laparoscopic dissection was necessary in 1.1% of LCs and a liver retractor was needed in 9 of the 11 cases. This technique does have a place and should be in the armamentarium of the laparoscopic surgeon.
逆行（“从底部开始”）解剖在开腹胆囊切除术中经常使用，虽然在腹腔镜胆囊切除术（LC）中可行，但尚未广泛应用。LC最简单的操作是使用抓钳进行顺行解剖，以提供向上的胆囊底部牵引。本文展示了一系列病例，以研究在经验丰富的腹腔镜外科医生手中使用现代器械进行逆行解剖的情况。
对一位经验丰富的腹腔镜外科医生在2004年被任命到布里斯托尔后进行的所有LC手术进行前瞻性记录。当在暴露和/或解剖胆囊三角遇到困难时采用逆行解剖。
共进行了1041例LC手术，其中包括148例（14%）急诊手术和131例（13%）相关的胆管探查术。尽管有6例患者（0.6%）需要转为开腹手术，但没有胆管损伤。11例患者（1.1%）成功尝试了逆行LC。年龄范围为28至80岁（平均61岁），男性7例。适应证为：纤维性、萎缩性胆囊7例，Mirizzi综合征2例，严重脊柱后凸2例。文中包含手术照片以展示需要该手术的病例类型及所使用的技术。术后住院时间为1/2至5天（平均2.2天），随访无延迟后遗症。组织病理学显示：慢性胆囊炎7例，黄色肉芽肿性胆囊炎3例，急性坏死性胆囊炎1例。
在本系列中，1.1%的LC手术需要进行逆行腹腔镜解剖，11例中有9例需要使用肝脏牵开器。这项技术确实有其应用价值，应成为腹腔镜外科医生的技术储备之一。
