腹腔镜胆囊切除术有或没有症状的胆石症（图文演示）

中文版：腹腔镜胆囊切除术用于有或无胆管造影的症状性胆石症（图文）

Laparoscopic cholecystectomy for symptomatic cholelithiasis with or without cholangiogram

Authors
D Mutter

Abstract
Cholecystectomy, consisting of complete removal of the gallbladder, was one of the first surgical interventions to be performed laparoscopically.
Laparoscopic cholecystectomy is performed using the same operative technique and principles as open cholecystectomy. Nonetheless, the two-dimensional downward to upward view coupled with the use of long instruments for distance manipulation requires specific training. Furthermore, the laparoscopic approach is associated with a risk of specific complications during the learning curve. One should always bear in mind that there is no such thing as a simple cholecystectomy.

Publication 2015-03

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老夏 发表于 2015-3-21 12:28
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19. Reference
▶
1. Overby DW, Apelgren K, Richardson W, Fanelli R, Society of American Gastrointestinal and Endoscopic Surgeons. SAGES guidelines for the clinical application of laparoscopic biliary tract surgery. Surg Endosc 2010;24:2368-86.
2. Berci G, Hunter J, Morgenstern L, Arregui M, Brunt M, Carroll B, Edye M, Fermelia D, Ferzli G, Greene F, Petelin J, Phillips E, Ponsky J, Sax H, Schwaitzberg S, Soper N, Swanstrom L, Traverso W. Laparoscopic cholecystectomy: first, do no harm; second, take care of bile duct stones. Surg Endosc 2013;27:1051-4.
3. Strasberg SM, Brunt LM. Rationale and use of the critical view of safety in laparoscopic cholecystectomy. J Am Coll Surg 2010;211:132-8.
4. Eikermann M, Siegel R, Broeders I, Dziri C, Fingerhut A, Gutt C, Jaschinski T, Nassar A, Paganini AM, Pieper D, Targarona E, Schrewe M, Shamiyeh A, Strik M, Neugebauer EA, European Association for Endoscopic Surgery. Prevention and treatment of bile duct injuries during laparoscopic cholecystectomy: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES). Surg Endosc 2012;26:3003-39.
5. Laurence JM, Tran PD, Richardson AJ, Pleass HC, Lam VW. Laparoscopic or open cholecystectomy in cirrhosis: a systematic review of outcomes and meta-analysis of randomized trials. HPB 2012;14:153-61.
6. Sun S, Yang K, Gao M, He X, Tian J, Ma B. Three-port versus four-port laparoscopic cholecystectomy: meta-analysis of randomized clinical trials. World J Surg 2009;33:1904-8.
7. Gurusamy KS, Vaughan J, Ramamoorthy R, Fusai G, Davidson BR. Miniports versus standard ports for laparoscopic cholecystectomy. Cochrane Database Syst Rev 2013;8:CD006804.
8. Flum DR, Dellinger EP, Cheadle A, Chan L, Koepsell T. Intraoperative cholangiography and risk of common bile duct injury during cholecystectomy. JAMA 2003;289:1639-44.
9. Sajid MS, Leaver C, Haider Z, Worthington T, Karanjia N, Singh KK. Routine on-table cholangiography during cholecystectomy: a systematic review. Ann R Coll Surg Engl 2012;94:375-80.
10. Alvarez FA, de Santibañes M, Palavecino M, Sánchez Clariá R, Mazza O, Arbues G, de Santibañes E, Pekolj J. Impact of routine intraoperative cholangiography during laparoscopic cholecystectomy on bile duct injury. Br J Surg 2014;101:677-84.
11. Sheffield KM, Han Y, Kuo YF, Townsend CM Jr., Goodwin JS, Riall TS. Variation in the use of intraoperative cholangiography during cholecystectomy. J Am Coll Surg 2012;214:668-79.
12. Gurusamy KS, Bong JJ, Fusai G, Davidson BR. Methods of cystic duct occlusion during laparoscopic cholecystectomy. Cochrane Database Syst Rev 2010;10:CD006807.
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14. Picchio M, Lucarelli P, Di Filippo A, De Angelis F, Stipa F, Spaziani E. Meta-analysis of drainage versus no drainage after laparoscopic cholecystectomy. JSLS 2014;18:00242.
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18. End of the procedure
• Extraction


The gallbladder is placed into an extraction bag and removed via the umbilical incision.
The use of an extraction bag offers 2 advantages:
- reduced risk of contamination of the umbilical incision by bile or stones in case of a gallbladder rupture during the extraction maneuvers,
- reduced risk of parietal wall seeding in cases of unrecognized gallbladder cancers.
The umbilical incision may enlarged as needed.

• Irrigation and lavage



In cases of bile leakage during the procedure, a lavage of the right upper quadrant can be realized.
Any spilled stones during the procedure should be looked for and extracted. Such stones can be the cause of early as well as late complications (abscess and chronic fistulae).

• Drainage

Under normal conditions in an elective setting, postoperative drainage is not indicated for laparoscopic or open cholecystectomy (Mutter, 1999).
If a drain is used, it must be a suction drain and must be removed relatively quickly. Indeed, prolonged postoperative drainage following open cholecystectomy has resulted in increased morbidity when it lasted more than 48 hours (Hoffmann, 1985; Playforth, 1985; Monson, 1986).

• Closure

At the end of the procedure, the pneumoperitoneum is evacuated after the trocar sites are carefully controlled for bleeding and the trocars are removed. Fascial closure is indicated for incisions >=10 mm in size.
Skin is closed based on the surgeon's preference using:
- clips;
- interrupted sutures;
- steristrips;
- surgical glue;
- or intracuticular sutures (recommended).

17. Gallbladder bed dissection
• Downward traction

Dissection of the gallbladder bed is performed by progressive use of electrocautery with a hook or scissors. Constant downward traction over the infundibulum of the gallbladder allows exposure for this operative time.

• Accessory biliary duct



The dissection of the gallbladder bed must be performed carefully to allow for the identification of any accessory biliary ducts draining directly into the gallbladder from the liver. Any such accessory ducts identified during the dissection of the gallbladder bed must be clipped.

16. CBD injuries
• Therapeutic options

The intraoperative recognition and identification of a CBD injury (either by direct vision or by cholangiography) normally mandates a conversion to laparotomy.
In rare cases, the treatment of select injuries can be done using the laparoscopic approach. Depending on the type of injury encountered, the therapeutic options are (Gigot, 1997):
- direct suturing without drainage;
- direct suturing over a T-tube;
- Roux-en-Y hepaticojejunal anastomosis.

• Dangers I
• Variation 1

                               
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Lateral clipping of the CBD

• Variation 2

Traumatic desinsertion of the cystic duct junction

• Variation 3

Tenting of the CBD

• Dangers II
• Variation 1

Instrument injury of the CBD during dissection of the triangle of Calot

• Variation 2

Instrument injury of the CBD during cholecystectomy

• Variation 3

Thermal injury of the CBD

• Variation 4

Injury to an anomalous right hepatic duct

• Variation 5

Injury to an anomalous right hepatic duct

• Variations
• Large cystic duct

If the cystic duct is too large to allow for safe clip application, ligation of the cystic duct stump becomes necessary. This can be done either with intracorporeal suturing or by application of a prefabricated loop.

• Difficult dissection


Difficult dissection of Calot's triangle:
In cases of difficulties encountered during simultaneous dissection of the cystic duct and cystic artery, it is possible to dissect, clip, and divide the cystic duct first. This maneuver will create additional operating space that will then allow the dissection, control, and safe division of the cystic artery.

• Clip application






Clip application with 3 mm scope

15. Clipping and division
• Anatomical structures


All important anatomical structures must be identified prior to clipping or division of the cystic duct in order to prevent injury to other vital structures in the region.

• Clipping and division


Clip application:
A 5 or 10 mm clip applicator is inserted through the lateral trocar on the left side (B) to allow placement of 3 clips on the cystic duct and 3 clips on the cystic artery:
- 2 clips are placed on the CBD side,
- 1 clip is placed on the gallbladder side.
Complete obliteration of the cystic artery and cystic duct by the clips is confirmed before division of these structures.

Division of the cystic duct:
The cystic duct is divided under direct vision.

Division of the cystic artery:
The cystic artery is divided under direct vision.