Fujiwara Sho, Kaino Kenji, Iseya Kazuki, Koyamada Nozomi
Department of Surgery, Iwate Prefectural Chubu Hospital, 17-10 Murasakino, Kitakami, Iwate, 024-8507, Japan.
Surg Case Rep. 2020 Sep 29;6(1):238. doi: 10.1186/s40792-020-01026-1.
Laparoscopic cholecystectomy (LC) for difficult acute cholecystitis (AC) cases bears a high risk of vasculobiliary injuries (VBI). The Tokyo Guidelines 2018 (TG18) recommend the use of bailout procedures and subtotal cholecystectomy to prevent VBI. Performing a safe LC is challenging, even when followed by an accurate pre-surgical assessment. Laparoscopic cholecystectomy (LSC) requires advanced skills, and there is a risk of recurrence of cancer and/or gallbladder stones (GBS) in the remnant gallbladder (GB). Moreover, it is sometimes impossible to safely close the cystic duct with either a loop tie or linear staples because of anatomical and fragility problems. Here, we report a novel technique employing barbed sutures for LSC in difficult AC cases.
We performed urgent LSC using barbed sutures for the stump of the cystic duct in two patients. In preoperative assessments, we found that these cases were qualified for operations rather than GB drainages, but the cystic ducts appeared difficult to close due to their severe inflammation and fragility during the operations. We applied barbed suture as a surrogate technique to close the stump of cystic duct. In patient 1, a 67-year-old woman with severe heart failure and type 2 diabetes mellitus was diagnosed with grade III AC. Pathological diagnosis was gangrenous cholecystitis. In patient 2, a 68-year-old woman who was referred to our hospital after 15 days of treatment for AC with antibiotics without drainage. The severity of AC was grade II according to TG18. Pathological diagnosis was acute-on-chronic cholecystitis. Both patients were discharged without complication.
The utilization of barbed sutures in LSC stems as a feasible and safe surrogate technique. Furthermore, this approach could decrease the risks associated with the remnant GB.
对于困难的急性胆囊炎（AC）病例，腹腔镜胆囊切除术（LC）存在较高的血管胆管损伤（VBI）风险。《东京指南2018》（TG18）建议采用补救手术和胆囊次全切除术来预防VBI。即使在进行准确的术前评估之后，实施安全的LC仍具有挑战性。腹腔镜胆囊切除术（LSC）需要先进的技术，并且残余胆囊（GB）存在癌症和/或胆结石（GBS）复发的风险。此外，由于解剖结构和脆弱性问题，有时无法用套扎线或直线吻合器安全地闭合胆囊管。在此，我们报告一种在困难的AC病例中使用倒刺缝线进行LSC的新技术。
我们对两名患者使用倒刺缝线对胆囊管残端进行了紧急LSC。在术前评估中，我们发现这些病例适合进行手术而非胆囊引流，但在手术过程中，由于胆囊管严重炎症和脆弱，似乎难以闭合。我们应用倒刺缝线作为替代技术来闭合胆囊管残端。患者1为一名67岁女性，患有严重心力衰竭和2型糖尿病，诊断为III级AC。病理诊断为坏疽性胆囊炎。患者2为一名68岁女性，在接受抗生素治疗AC 15天后未进行引流被转诊至我院。根据TG18，AC的严重程度为II级。病理诊断为慢性胆囊炎急性发作。两名患者均无并发症出院。
在LSC中使用倒刺缝线是一种可行且安全的替代技术。此外，这种方法可以降低与残余GB相关的风险。
