Endocutterによる胆囊管処理法―手技の実際と安全性について―

Management of the cystic duct with EndopathⓇEndocutter during laparoscopic cholecystectomy

◆要旨：胆囊管の著しい壁肥厚・短縮のために，腹腔鏡下の胆囊管処理が困難な場合がある．今回Endopath^ⓇEndocutter（6TB45 : 45mm，6列，青：Ethicon Endo-Surgery）による胆囊管処理を12例に施行した．手術時間は60～175分で，開腹移行はなかった．全例に術中超音波検査（Lap-US）で胆囊管のオリエンテーションをつけた後にEndocutterによる処理を行った．3例でLap-USのみではオリエンテーションが不十分と判断し，底部から順行性に胆囊を剝離（dome down）した．術後在院日数は3～7日で，合併症は認めなかった．Endocutterによる胆囊管処理は簡便で安全性も高いと考えられた．本法を安全に行うためには，胆囊管のオリエンテーションを確実につける必要があり，Lap-USは不可避であり，dome-down techniqueも時に選択すべきである．

　Cutting and ligation of the cystic duct（c-duct）during laparoscopic cholecystectomy（Lap-chol）is sometimes very difficult in patients with severe inflammation around the duct. Here we demonstrate our technique using the Endopath*Endocutter device（6 TB 45 : 45 mm, 6 row, blue cartridge ; Ethicon Endo-Surgery, USA）for management of the c-duct during lap-chol, and evaluate its safety and effectiveness. Twelve patients with marked wall thickening and/or shortening of the c-duct were studied. In all patients, laparoscopic ultrasound（Lap-US）was performed to accurately determine the orientation of the c-duct in relation to the common bile duct（CBD）. When the orientation of the c-duct was hard to access, the dome-down technique was employed. The operating time was 60 to 175 minutes and no patient was converted to open surgery. There were no complications. After Lap-chol, the hospital stay ranged from 3 to 7 days. Management of the c-duct with the Endopath^ⓇEndocutter device is safe and easy, but should be done carefully to avoid CBD injury. In this report, the necessity of Lap-US and/or the dome-down technique for this method is emphasized.