胆囊動脈閉鎖クリップが関与し興味ある経過をとった腹腔鏡下胆囊摘出術後の胆汁瘻の1例

Delayed bile leakage due to pressure necrosis of the common bile duct by a clip after laparoscopic cholecystectomy

◆要旨：患者は62歳，男性で，胆囊結石症に対する腹腔鏡下胆囊摘出術後，第5病日に，腹痛が出現し，CT，腹腔穿刺を施行し胆汁瘻と診断した．内視鏡的治療が困難であったため，開腹手術を行った．胆囊動脈処理のクリップの端が総胆管に接し胆汁が漏出しており，クリップによる総胆管圧迫壊死のための胆汁漏と診断した．1期的に縫合閉鎖を行い，再手術後は経過良好で退院している．胆囊炎による癒着のため広範に剝離を要し，胆囊動脈処理のクリップが総胆管に接する状態となったことが原因と考えられた．このような症例では，術後の総胆管壊死予防に注意を払う必要があると考える．

　We report a rare case of delayed bile leakage due to pressure necrosis of the common bile duct （CBD） by a clip after laparoscopic cholecystectomy. A 62-year-old male underwent a laparoscopic cholecystectomy for cholecystolithiasis. He developed abdominal pain on the 5^th post operative day. The CT scanning showed liquid collection in his peritoneal cavity. He was diagnosed as having a bile duct injury by percutaneous aspiration of the bile collection. Because we failed direct cholangiography and the insertion of an endoscopic nasobiliary drainage tube, open repair was performed. Emergent laparotomy showed a hole, 1mm in size, in the CBD thatwas perforated by a clip fixed onto the cystic artery. We were able to suture the damaged lesion. The patient was discharged uneventfully after the second operation. Attention should be paid to the fact that a clip may perforate the wall of the CBD.