高度慢性胆囊炎を合併した左側胆囊結石症に腹腔鏡下胆囊摘出術を施行した1例

Laparoscopic cholecystectomy in a patient with a left-sided gallbladder and severe chronic cholecystitis : a case report

◆要旨：術前診断した高度慢性胆囊炎を有する左側胆囊結石症に対する腹腔鏡下胆囊摘出術を経験した．患者は75歳，女性．右季肋部痛を主訴に近医を受診した，超音波検査で胆囊結石症と診断され．DIC-CT所見にて肝内胆管の走行異常とともに左側胆囊と診断された．手術は4孔吊り上げ式で施行し，腹腔内所見でも左側胆囊を確認した．炎症が高度な萎縮胆囊で，胆囊摘出術は難渋した．2mmポートを肝円索把持用に使用し，圧排用鉗子で十二指腸・大網を押さえることが視野展開に有効だった．胆囊摘出術は順行性に行い，胆囊頸部を一度横断し，結石・胆囊組織を回収袋に回収し，術中胆道造影検査で胆管走行を確認し，胆囊摘出を完了した．難易度が高い左側胆囊症例でも，正確な術前診断，種々の工夫により安全に施行できた．

　We describe here laparoscopic cholecystectomy（LC）performed on a patient with severe chronic cholecystitis with a left-sided gallbladder. A 75-year-old woman with right subcostal pain was diagnosed with gallbladder stones by ultrasonography. Computed tomography with biliary contrast medium suggested that her intrahepatic bile ducts were abnormal, and she was found to have a left-sided gallbladder. A laparoscopic cholecystectomy was performed using the abdominal wall lifting method with 4 ports, and she was confirmed as having a left-sided gallbladder. Use of a snake retractor to suppress the duodenum and omentum and a 2-mm port for holding the round ligament of the liver was effective in widening the visual field and working space. Cholecystectomy was performed from the fundus, transecting the body to confirm the anatomy, and stones and tissue were collected in a bag by the piece by piece method. We concluded that LC was safe even in such a complicated case through accurate preoperative diagnosis and by the surgical methods described here.