有关腹腔镜胆囊切除术中转开腹97 例分析
【摘要】 探讨腹腔镜胆囊切除术(LC) 中转开腹对减少并发症,提高手术质量的重要性。 方法: 回顾分析总结97 例LC中转开腹的原因。 结果:主动中转开腹(因解剖不清,尚未发生并发症时即中转开腹)病例62 例,主要原因为Calot 三角严重粘连、胆囊萎缩及解剖变异。术后没有严重并发症发生,术后平均住院日为9.72d ;被动中转开腹(发生胆道损伤、大出血等并发症后中转开腹) 病例35例，术后出现严重并发症,术后平均住院日为17.71d。 结论:当LC 术中遇到Calot 三角严重粘连、胆囊管结石嵌顿、胆囊萎缩及解剖变异等手术难度超出术者处理能力时应适时主动中转开腹以避免或减少并发症的发生。【关键词】 腹腔镜胆囊切除术 转开腹
Abstract:Objective: To discuss the importance of conversion into surgery for decreasing complications and achieving better operative results during laparoscopic cholecystectomy (LC) . Methods:The causes of conversion into surgery were reviewed in 97 patients undergoing LC. Results:The main causes were intensive dense adhesion of Calot’s triangle ,shrunken gallbladder and abnormal anatomy in 62 cases undergoing LC of active conversion into surgery. The main causes were common bile duct injury and rapid hemorrhage in 35 cases receiving LC of passive conversion into surgery. The average postoperative stay for the active conversion into surgery were 9.72 days and 17.71 days for the passive conversion . In addition ,there was no complication in active conversion into surgery versus 8 complications in passive conversion into surgery . Conclusion:The active conversion into surgery should be considered at the right moment for preventing or decreasing complications of LC once intensive dense adhesion of Calot’s triangle ,stone incarceration on the neck of the gallbladder ,shrunken gallbladder and abnormal anatomy occurred during laparoscopic cholecystectomy.
Key words: Laparoscopic Cholecystectomy ; Conversion Laparotomy ; Cause
随着腹腔镜技术的推广普及,LC 以其创伤小、痛苦小、瘢痕小、恢复快等优越性已得到广泛认可。且随着LC技术日益成熟，LC 的指征逐渐放宽,从而使相当一部分较复杂病例的LC 得以实施,术中遇到的`因病变或技术因素导致的特殊情况及疑难问题也随之增加,若手术处理不当易损伤胆道和邻近脏器,引起严重并发症。为了保证手术的安全,避免或防止并发症的发生,术前对手术难度的充分估计及术中适时中转开腹是非常重要的。现就我院LC 中转开腹原因分析如下:
1 临床资料
我院自1993年2月至2006年12月共开展腹腔镜胆囊切除术6051例, 均因胆囊结石伴急性或慢性胆囊炎、胆囊息肉行LC 术。因各种原因中转开腹97 例(占1.60 %) ,其中择期手术5407 例,中转58 例(占1. 07 %)；急症手术644 例,中转39 例(占6. 05 %) 。有国外文献报道LC 中转开腹率为1. 6 %～11. 4 %［1］,急症LC中转率高达20. 5 %［2］ 。本组97 例,其中男45 例,女52 例,年龄14～72 岁，中位年龄38. 7 岁 。胆囊结石伴慢性胆囊炎22例，胆囊结石伴慢性胆囊炎急性发作31例, 胆囊结石伴急性胆囊炎39 例,胆囊息肉5 例。其中2 例合并2型糖尿病, 既往有腹部手术史12 例。
2 结 果
中转开腹97 例中胆囊与周围炎性粘连、三角区解剖不清51 例,占52.58 %; 3 例胆囊与胃肠粘连,占3.09 %；其中2 例为胆囊十二指肠瘘, 占2.06 % ;1 例为胆囊结肠瘘, 占1.03 %; 胆囊管变异5 例，占5.15 %; 26 例怀疑胆道损伤,占26.80 %;7 例胆囊动脉出血,占7.21 %;胆囊床广泛渗血不止2 例,占2.06 %。全组97 例均一次性完成手术,无死亡病例。主动中转开腹62 例,均恢复良好,没有严重并发症发生,术后平均住院天数为9.72d ;被动中转开腹35 例,手术难度加大,出现严重并发症,其中胆瘘3 例,胆总管狭窄5 例,住院时间延长,术后平均住院天数为17.71d。