Iso Y, Kusaba I, Matsumata T, Okita K, Murakami N, Nozoe T, Funahashi S, Adachi Y, Yoh R, Sugimachi K
Department of Surgery, Saiseikai Yahata General Hospital, Kitakyushu, Japan.
Am J Gastroenterol. 1996 Nov;91(11):2428-30.
A 61-yr-old man underwent Billroth I gastrectomy for an advanced cancer in the corpus of the stomach. On the first postoperative day, fresh bile discharged from the penrose drains, which had been placed in Winslow's foramen, and the volume of bile discharge subsequently increased. Leakage from the gastroduodenal anastomosis was excluded by gastroduodenography. Exploratory relaparotomy showed bile peritonitis with much more bile retention in the left subphrenic space. The origin of bile leakage could not be traced despite close examination of all the extrahepatic biliary tract and the liver surface. Intraoperative cholangiography through the cystic duct after cholecystectomy revealed that the bile leakage originated from an aberrant bile duct present in the free edge of the left triangular ligament (appendix fibrosa hepatis), which had been unintentionally cut at the primary operation. Knowledge of this anatomical structure is important and proper ligation is recommended when dissecting the appendix fibrosa hepatis to avoid postoperative bile peritonitis and the need for a relaparotomy.
一名61岁男性因胃体部进展期癌接受了毕罗Ⅰ式胃切除术。术后第一天，置于网膜孔的烟卷式引流管引出新鲜胆汁，随后胆汁引流量增加。胃十二指肠造影排除了胃十二指肠吻合口漏。剖腹探查显示胆汁性腹膜炎，左膈下间隙胆汁潴留更多。尽管对所有肝外胆道和肝表面进行了仔细检查，但仍未找到胆汁漏的源头。胆囊切除术后经胆囊管进行术中胆管造影显示，胆汁漏源于左三角韧带（肝纤维附件）游离缘存在的一条迷走胆管，该胆管在初次手术时被意外切断。了解这一解剖结构很重要，在解剖肝纤维附件时建议妥善结扎，以避免术后胆汁性腹膜炎和再次剖腹手术的需要。
