Hunter J G
Emory University School of Medicine, Atlanta, Georgia.
Am J Surg. 1993 Apr;165(4):492-6. doi: 10.1016/s0002-9610(05)80948-1.
The technical complications of laparoscopic cholecystectomy occur while creating the pneumoperitoneum, placing trocars, obtaining exposure, and performing the initial dissection of the cystic duct and artery. The errors most feared are intestinal injury, vascular injury, and common bile duct injury. Bile duct injury usually results from the misinterpretation of the extrahepatic biliary anatomy. Confusion is most likely if the gallbladder infundibulum is pushed superiorly and medially, pulling the common bile duct out from behind the duodenum and into line with the cystic duct and gallbladder. Other dissection errors resulting in bile duct injury include the failure to begin dissection on the gallbladder, routine dissection of the cystic duct all the way to the common bile duct, failure to identify anomalies of the cystic and hepatic ducts, failure to open all folds of the gallbladder infundibulum, and entrapment of a narrow common bile duct by a cystic duct clip "slid" too far proximally. Proper dissection strategy includes posterolateral traction on the gallbladder infundibulum and initiation of dissection at the most medial point where the gallbladder is clearly seen. Pedunculation of the gallbladder will reveal most ductal anomalies but should be supplemented with routine digital fluoroscopic cholangiography. The controversy over optimal sources for thermal dissection of the gallbladder has largely been resolved. Electrosurgical dissection is a more rapid, hemostatic, and economical dissection.
腹腔镜胆囊切除术的技术并发症发生于建立气腹、放置套管针、获得暴露以及对胆囊管和动脉进行初始解剖的过程中。最令人担忧的失误是肠损伤、血管损伤和胆总管损伤。胆管损伤通常源于对肝外胆管解剖结构的错误解读。如果将胆囊漏斗部向上和向内推，将胆总管从十二指肠后方拉出并与胆囊管和胆囊对齐，就极有可能造成混淆。导致胆管损伤的其他解剖失误包括未从胆囊开始解剖、常规将胆囊管一直解剖至胆总管、未识别胆囊管和肝管的异常、未打开胆囊漏斗部的所有皱襞以及胆囊管夹向近端“滑”得太远而夹住狭窄的胆总管。正确的解剖策略包括对胆囊漏斗部进行后外侧牵引，并在能清楚看到胆囊的最内侧点开始解剖。胆囊蒂处理可发现大多数导管异常，但应辅以常规数字荧光胆管造影。关于胆囊热解剖的最佳来源的争议在很大程度上已得到解决。电外科解剖是一种更快速、止血且经济的解剖方法。
