胆囊管分枝異常を伴った慢性胆囊炎に対する腹腔鏡下胆囊摘出術の1例

Laparoscopic cholecystectomy for chronic cholecystitis with anomaly of cystic duct branching : a case report

◆要旨：患者は62歳，女性で，胆囊結石症の診断にて腹腔鏡下胆囊摘出術を施行したが，高度の炎症のためにCalot三角の解剖が不明であった．術中の穿刺胆道造影にて胆囊管が右肝管より分枝する走行異常を伴うことが判明した．この所見をもとに，Calot三角背側からの直視下での剝離操作で右肝管と胆囊管を同定剝離することが可能であった．本症例では術中の穿刺胆道造影が胆管の解剖の把握に非常に有用であった．また，flag techniqueを駆使してのCalot三角の背側から直視下での剝離操作でcritical viewを得ることが胆管走行異常を伴う高度炎症症例に対しては，胆管損傷の回避において重要と考えられた．

　We report a 62-year-old woman with gallstones and an anomaly of cystic duct branched from right hepatic duct who successfully underwent laparoscopic cholecystectomy（LC）. At first, anatomy of Calot's triangle was not clear due to severe inflammation. However, right hepatic duct and cystic duct were safely confirmed by dissection under direct view from the dorsal side of Calot's triangle with a guide of intraoperative puncture cholangiography. In this case, intraoperative puncture cholangiography was very useful in understanding the anatomy of the biliary tract. It is important to obtain a critical view by dissection under direct view from the dorsal side of Calot's triangle using flag technique to avoid bile duct injury in the case of severe inflammation with biliary tract anomaly.