Perissat J
Service de Chirurgie Digestive, Centre Hospitalier Universitaire, Bordeaux, France.
Am J Surg. 1993 Apr;165(4):444-9. doi: 10.1016/s0002-9610(05)80938-9.
Laparoscopic cholecystectomy, initially performed in France in 1987, has rapidly spread to other European countries, the United States, and elsewhere. Of the techniques that have evolved, the "French" technique, in which the surgeon stands between the patient's legs, and the "American" technique, in which the surgeon stands on the patient's left side, are the most commonly used. In the former technique, the liver is retracted via the mid-clavicular cannula and the infundibulum of the gallbladder via the anterior axillary port. In the latter technique, the liver is retracted by axial traction on the gallbladder through the anterior axillary cannula and the infundibulum through the mid-clavicular cannula. This position may increase the risk of bile duct injury. The technique selected for operative cholangiography should be adapted to the problem at hand. Cystic duct cholangiography shows ductal calculi more reliably due to better filling of the common bile duct; direct puncture of the gallbladder is safer when the biliary anatomy is unclear. A number of European studies confirm the safety of laparoscopic cholecystectomy. Mortality rates vary between 0% and 0.1%, and duct injury rates range between 0.2% and 0.6%. Conversion, which is done in 3% to 8% of cases, may be necessary in the case of uncontrollable hemorrhage, bile duct injury unsuitable for laparoscopic repair, or if the gallbladder is densely scarred (scleroatrophic). It can also be done for safety reasons, when the anatomy is unclear. Complications include bile collections due to accessory duct or cystic duct stump leaks or less commonly to common duct injury. The average postoperative stay is longer in Europe (3.2 days) than in the United States. A decision tree is presented for the management of common bile duct stones. In general, preoperatively identified ductal stones are removed by endoscopic sphincterotomy, which is then followed by laparoscopic cholecystectomy to remove the source of the calculi. The techniques of laparoscopic choledochotomy and transcystic exploration for the removal of stones in the common bile duct are only beginning to be used, but they may well prove to be the most popular procedures. Results with these procedures will need to be evaluated against those obtained with endoscopic sphincterotomy.
腹腔镜胆囊切除术于1987年在法国首次开展，迅速传播至其他欧洲国家、美国及其他地区。在已发展的技术中，“法国”技术（外科医生站在患者双腿之间）和“美国”技术（外科医生站在患者左侧）最为常用。在前一种技术中，通过锁骨中线套管牵拉肝脏，通过腋前线端口牵拉胆囊漏斗部。在后一种技术中，通过腋前线套管对胆囊进行轴向牵拉以牵拉肝脏，通过锁骨中线套管牵拉漏斗部。这种体位可能增加胆管损伤风险。选择用于术中胆管造影的技术应根据手头的问题进行调整。胆囊管胆管造影由于能更好地充盈胆总管，显示胆管结石更可靠；当胆道解剖结构不清楚时，直接穿刺胆囊更安全。多项欧洲研究证实了腹腔镜胆囊切除术的安全性。死亡率在0%至0.1%之间，胆管损伤率在0.2%至0.6%之间。3%至8%的病例需要中转开腹，在出现无法控制的出血、不适合腹腔镜修复的胆管损伤、或者胆囊严重瘢痕化（硬化萎缩性）的情况下可能有必要中转，也可能出于安全原因在解剖结构不清楚时进行中转。并发症包括由于副胆管或胆囊管残端漏出导致的胆汁积聚，较少见的是胆总管损伤导致的胆汁积聚。欧洲的平均术后住院时间（3.2天）比美国长。给出了一个用于胆总管结石处理的决策树。一般来说，术前发现的胆管结石通过内镜括约肌切开术取出，然后进行腹腔镜胆囊切除术以去除结石来源。用于胆总管结石取出的腹腔镜胆总管切开术和经胆囊探查技术才刚刚开始应用，但很可能会成为最受欢迎的手术方式。这些手术的结果需要与内镜括约肌切开术的结果进行对比评估。
