Keens Keta L, Pursnani Kishore G, Ward Jeremy B, Date Ravindra S
Postgraduate Department, Lancashire Teaching Hospital Foundation Trust, Chorley, UK.
BMJ Case Rep. 2013 Feb 1;2013:bcr2012007798. doi: 10.1136/bcr-2012-007798.
Common bile duct injury is infrequent but a serious complication of cholecystectomy. Variable biliary anatomy has an increased risk of iatrogenic injury. Intraoperative cholangiogram can be performed to provide a clearer picture of biliary anatomy. We report a case of a 71-year-old lady who underwent cholecystectomy for symptomatic gallstones. Anatomy initially was misinterpreted at laparoscopy when common bile duct was identified as a cystic duct, and a hole in what appeared to be Hartmann's pouch was in fact in common hepatic duct. If continued laparoscopically, further misconception could have led to the complete excision of the biliary system. Instead, procedure was converted to an open and intraoperative cholangiogram performed, which confirmed a diagnosis of Mirizzi syndrome. Following the identification of structures, subtotal cholecystectomy was completed. The patient made an uneventful recovery. This case highlights the limitations of laparoscopy and the importance of an intraoperative cholangiogram. Despite advances in surgical techniques, we continue to advocate a low threshold for its use during cholecystectomy as a useful tool in evaluating and minimising the extent of biliary injury.
胆总管损伤并不常见，但却是胆囊切除术的一种严重并发症。胆管解剖结构变异会增加医源性损伤的风险。术中胆管造影可用于更清晰地显示胆管解剖结构。我们报告一例71岁女性患者，因有症状的胆结石接受胆囊切除术。在腹腔镜手术中，最初解剖结构被误判，胆总管被误认为是胆囊管，而在看似是哈特曼袋的地方出现的一个洞实际上位于肝总管。如果继续进行腹腔镜手术，进一步的误解可能会导致胆管系统被完全切除。相反，手术转为开腹并进行了术中胆管造影，证实为Mirizzi综合征。在明确结构后，完成了次全胆囊切除术。患者恢复顺利。该病例突出了腹腔镜手术的局限性以及术中胆管造影的重要性。尽管手术技术有所进步，但我们仍然主张在胆囊切除术中，将其作为评估和最小化胆管损伤程度的有用工具，保持较低的使用门槛。
