腹腔鏡下肝囊胞開窓術にて走行異常の左肝管を切断し再手術を要した1例

Resection of left hepatic duct through laparoscopic fenestration of liver cyst : a case report

腹腔鏡下肝囊胞開窓術にて走行異常の左肝管を損傷し，再手術を要した１例を経験した．症例は60歳代，女性．腹部膨満感よりCTにて7個の肝囊胞を認め，最大のものは15cm超で肝前区域から内側区域を占拠していた．腹腔鏡下開窓術を施行し，術中，胆汁漏を認めたが，胆管末梢枝の判断でクリップにて閉鎖した．しかし，術後胆汁漏が続き，DIC-CTにて左肝管の途絶を認め，再手術を行った．結局，囊胞の圧排により左肝管のみグリソンから分離され囊胞前壁を走行しており，同部を含めた開窓による胆管損傷であった．腹腔鏡下囊胞開窓術は簡便な手法と思われるが，本症例のような胆管系の走行異常も十分に念頭に置き，治療すべきと思われた．

　We report a patient with left hepatic duct anomaly that was resected through laparoscopic fenestration of a liver cyst. The patient visited the hospital complaining of abdominal distension. Computed tomography revealed seven liver cysts. The maximal cyst, exceeding 15 cm in size, occupied the segmentum mediale from segmentum anterius of the liver. Laparoscopic fenestration was performed. Although bile leakage was noted from the fenestration site during the operation, judging the leakage to be from peripheral bile duct, it was blocked using the clip. However, postoperative bile leakage continued. The result of DIC-CT suggested that the left hepatic duct was cut, and reoperation was performed. Only the left hepatic duct turned out to be separated from the Glisson's sheath and it was located at the anterior wall of the cyst. Fenestration of the anterior wall was performed. Although laparoscopic fenestration of liver cyst is a good procedure, we should be careful for the anomaly of bile duct, as in this case.