術中に明らかとなった腹腔鏡下左側胆囊摘出術の1例

A case of laparoscopic cholecystectomy for a left-sided gallbladder, diagnosed intraoperatively

◆要旨：肝内門脈分岐異常を伴う左側胆囊を腹腔鏡下に摘出した症例を経験した．患者は39歳，女性で，2006年5月に胆囊結石症の診断にて腹腔鏡下胆囊摘出術を施行した．胆囊窩が肝円索の左側，肝外側区域に位置する左側胆囊であった．従来通り，臍下部，心窩部，右鎖骨中線上，右前腋窩線上にポートを挿入した．鉗子の動きが制限され，胆囊管や胆囊動脈の同定と切離，および胆囊の剝離に難渋した．術前画像を後日再検討したところ，腹部CTとMRIにおいて右肝円索が認められ，胆囊窩はその左側に位置していた．また，門脈右枝に臍部を形成していた．自験例への反省から，左側胆囊に対して腹腔鏡下胆囊摘出術を施行した25例を集計し，門脈分岐異常，胆囊管の合流部位，胆囊窩の位置，術中の工夫などを比較検討した．

　We report a case of left-sided gallbladder combined with an anomaly of the intrahepatic portal vein. A 39-year-old woman underwent laparoscopic cholecystectomy for symptomatic cholecystolithiasis. Intraoperative finding showed that the gallbladder was located under the left hepatic segments at the left of the hepatic round ligament. We used four ports placed in the infraumbilical region, the epigastric region, the right midclavicular region and the right anterior axillary line in the usual manner. The movement of laparoscopic forceps were strikingly restricted because of inappropriate places of four ports inserted for left-sided gallbladder, we had difficulty in the identification and the dissection of the cystic duct and the cystic artery and the removal of the gallbladder from the hepatic bed. A retrospective analysis of abdominal computed tomography（CT）and magnetic resonance imaging（MRI）revealed the right hepatic round ligament and the gallbladder lying to the left of the right hepatic round ligament. From our experience, we reviewed 25 cases including our case in the Japanese literature concerning left-sided bladders removed laparoscopically, in terms of anomalies of portal vein, places where cystic ducts terminated, places of gallbladder fossa and special procedures.