Segment IV approach for difficult laparoscopic cholecystectomy
Segment IV approach for difficult laparoscopic cholecystectomy
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DOI：
10.1002/ags3.12297
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发表时间：
2019-11-11
影响因子：
2.7
通讯作者：
Yanaga, Katsuhiko
中科院分区：
文献类型：
--
作者：
Kitamura, Hiroaki;Fujioka, Shuichi;Yanaga, Katsuhiko
尽管实现安全临界观（CVS）有助于避免腹腔镜胆囊切除术（LC）期间的血管胆道损伤，但由于技术困难，在严重胆囊炎的情况下并不总能实现CVS。在此，我们重点关注肝脏的 IV 段及其对角线（D 线），作为进行困难 LC 的可行标志。 D 线连接 IV 段的右背角和左腹角，用作矢量标志，这是首先解剖胆囊以实现 CVS 而不会误识别的位置。当胆囊壁疤痕严重时，沿 D 线转换为胆囊次全切除术也是可行的。我们将此程序命名为 LC 的 IV 段方法。连续 62 例困难 LC（包括 27 例经皮肝穿刺胆囊引流术 [PTGBD] 后预定 LC 和 35 例东京指南 [TG] 二级胆囊炎保守治疗病例）采用 IV 段入路治疗。 44 例 (71%) 例沿 D 线成功切除胆囊；所有这些病例在全胆囊切除术后也实现了 CVS。其余18例（29%）因严重胆囊炎且与周围结构炎性粘连，导致沿D线胆囊摘除失败，转为胆囊次全切除术。中位手术时间和术中失血量分别为 135 分钟（范围，54-290）分钟和 10（范围，0-100）毫升。未观察到术中或术后并发症。 IV 段入路对于实现 CVS 以及在存在胆囊壁疤痕的困难 LC 病例中考虑进行胆囊次全切除术是可行的。
Although achieving the critical view of safety (CVS) is useful for avoiding vasculobiliary injury during laparoscopic cholecystectomy (LC), the CVS cannot always be achieved in cases of severe cholecystitis because of technical difficulties. Herein, we focused on segment IV of the liver and its diagonal line (D-line) as a feasible landmark for carrying out difficult LC. The D-line connects the right dorsal and left ventral corners of segment IV and is used as the vectoral landmark, which is where the gallbladder is first dissected to achieve CVS without misidentification. Conversion to subtotal cholecystectomy along the D-line is also feasible when gallbladder wall scarring is severe. We named this procedure the segment IV approach for LC. Sixty-two consecutive difficult LC (including 27 scheduled LC after percutaneous transhepatic gallbladder drainage [PTGBD] and 35 conservatively treated cases of Tokyo Guidelines [TG] grade II cholecystitis) were managed by the segment IV approach. Successful gallbladder extraction along the D-line was achieved in 44 (71%) cases; all of these cases also achieved CVS following total cholecystectomy. The other 18 (29%) cases were converted to subtotal cholecystectomy because gallbladder extraction along the D-line failed as a result of severe cholecystitis with inflammatory adhesion with surrounding structures. Median operative time and intraoperative blood loss were 135 (range, 54-290) min and 10 (range, 0-100) mL, respectively. No intra- or postoperative complications were observed. The segment IV approach is feasible for achieving CVS and for considering subtotal cholecystectomy in difficult LC cases where scarring of the gallbladder wall is present.