腹腔鏡下胆囊摘出術における胆囊床出血の予防と対策―術前超音波検査による胆囊床血管観察の有用性―

Usefulness of ultrasound to depict vascular anatomy of the bed of the gallbladder

◆要旨：「日本内視鏡外科学会―第8回アンケート調査」によると，腹腔鏡下胆囊摘出術の二大偶発合併症は胆管損傷と開腹止血を要した出血である．後者の内訳は，胆囊動脈・胆囊床が多い．筆者らは，胆囊床出血を予防するために血管解剖が重要と考え，これを知るうえでの超音波検査（ultrasound；以下，US）の有用性を検討した．同手術347症例に対して術前USを行い，胆囊床への肝血管進入の有無を観察した．中肝静脈枝94例，P5門脈枝14例，両者3例の胆囊床進入を認め，術中に中肝静脈枝とP5門脈枝の出血を各1例で経験したが，腹腔鏡下に縫合止血しえた．一方，肝血管進入が不明瞭な236例ではさほどの胆囊床出血はなかった．USは，胆囊床血管の解剖を把握し，胆囊床出血を予防するうえで有用であった．

　The 8th investigation report summing up answers to questionnaires on endoscopic surgery disclosed that the major two complications of laparoscopic cholecystectomy were the bile duct injury and the hemorrhage requiring open-method hemostasis. The latter mainly comprised of that from cystic artery or fossa for the gallbladder. Understanding the vascular anatomy of the bed of the gallbladder is important for the prevention of hemorrhage. Therefore, the usefulness of ultrasound to depict vascular anatomy of the site was examined in the recent consecutive 347 patients who underwent laparoscopic cholecystectomy. At the fossa for the gallbladder, ultrasound demonstrated 94 patients（27.1％）having middle hepatic vein branches, 14 patients（4.0％）having portal vein branches, and 3 patients（0.9％）having both. Among these patients, one patient had hemorrhage from a middle hepatic vein branch and another from a portal vein branch. Hemostasis with Z-suture was successful for both these patients. On the other hand, in the 236 patients（68.0％）whose middle hepatic vein branch and portal vein branch could not be demonstrated by ultrasound at the bed of the gallbladder, there were no significant hemorrhages from the site during laparoscopic cholecystectomy. Ultrasound is useful to depict vascular anatomy of the bed of the gallbladder and to prevent hemorrhage from those sites.