腹腔鏡下総胆管切石術後に起きた吸収性クリップによる十二指腸穿孔の1例

A case of duodenal perforation caused by the cystic duct clip used in laparoscopic common bile duct lithotomy

腹腔鏡下胆囊摘出術は，胆囊管損傷や血管損傷といった危険性がある．今回，筆者らは腹腔鏡下総胆管切石術後，吸収性クリップにより十二指腸穿孔を合併した症例を経験したので文献的考察を加えて報告する．症例は65歳，男性．発熱，黄疸を主訴に近医を受診し，総胆管結石症と診断された．手術目的に当院を紹介され入院となった．2002年8月上旬，腹腔鏡下総胆管切開切石術＋Tチューブドレナージを行った．術後9日目よりTチューブ刺入部周囲より出血を認めた．内視鏡にてクリップによる十二指腸穿孔を認めたため緊急手術を行った．腹腔鏡下総胆管切開切石術＋Tチューブドレナージを行う際には，気腹終了後の位置関係を十分に考慮したうえでTチューブ留置位置，クリップの角度を決定する必要があり，トロッカーの挿入位置にも注意を払う必要があると考えられた．

　Laparoscopic cholecystectomy involves the risk of bile duct injury and blood vessel injury. We experienced a case which was complicated by duodenum perforation by an absorptive clip after laparoscopic choledocholithotomy. The case is 65-year old man who consulted a physician with a chief complaint of fever and jaundice. The patient was diagnosed with common bile duct stone. He was referred to our hospital for operation. Laparoscopic choledocholithotomy＋T Tube dorainage was performed in the beginning of August, 2002. On the 9th post operative day, hemorrhage was defected in the T tube. Endoscopy revealed duodenum perforation caused by the clip, and emergency surgery was performed.

　From our experience, T-tube placement and clip application must be determined carefully after pneumoperitoneum, in order to avoid this complication.