腹腔镜胆囊切除术中转开腹评估体系的建立及手术分级管理探索

doi:10.16139/j.1007-9610.2025.01.10

摘要/Abstract

摘要：

目的： 探讨并建立一个根据术前临床资料预测腹腔镜胆囊切除术（LC）中转开腹可能性的评分体系并以此建立手术分级管理模式。方法： 回顾性研究仁和医院及华山医院2013年6月至2018年6月9 414例行LC病人的临床资料，分为LC组（9 246例）和中转开腹组（168例），将两组资料进行比较，用卡方检验单因素分析筛选出影响中转开腹的危险因素，再对危险因素行Logistic多元回归分析，并根据所建中转开腹可能性函数对危险因素各变量前系数进行赋值，计算每个病例的得分后，比较各得分组的实际中转开腹率的差异。计算受试者工作特征(ROC)曲线下面积评价该评分系统的效能。根据评分体系同时创建LC手术分级管理模式并进行验证。结果： 体温≥38.5℃、急性胆囊炎发作次数≥3次、胆囊壁最大厚度≥5 mm、胆囊颈部结石嵌顿、胆总管直径≥8 mm、术者经验≤50例是中转开腹的危险因素（P<0.001）。评分系统>3分，中转开腹风险高。结论： 该LC评分体系及手术分级管理可靠有效，可降低LC中转开腹率。

关键词: 腹腔镜, 胆囊切除术, 中转开腹, 危险因素, 评分系统

Abstract:

Objective To develop and validate a scoring system to predict the possibility of laparoscopic cholecystectomy (LC) conversion to laparotomy based on preoperative clinical data, and to establish a grading management model of surgery. Methods A retrospective analysis was conducted on the clinical data of 9 414 patients who underwent LC at Renhe Hospital and Huashan Hospital from June 2013 to June 2018. The patients were divided into two groups: the LC group (9 246 patients who successfully underwent LC) and the conversion to laparotomy group (168 patients who required conversion to open surgery). The data of two groups were compared, and the risk factors affecting conversion to laparotomy were screened out by single factor analysis of Chi-square test. Then, the risk factors were analyzed by multiple Logistic regression, and the pre-coefficient of each variable of the risk factors was assigned according to the established conversion to laparotomy possibility function. After calculating the score of each case, the difference in the actual conversion rate of each group was compared. The area under receiver operating characteristic (ROC) curve was calculated to evaluate the performance of the scoring system. According to the scoring system, LC surgical grading management model was created and verified. Results The following factors were identified as significant risk factors for conversion to laparotomy (P < 0.001): body temperature ≥ 38.5℃, frequency of acute cholecystitis ≥3 times, maximum thickness of gallbladder wall ≥ 5 mm, gallbladder neck stone incarceration, diameter of common bile duct ≥8 mm, and surgical experience ≤50 cases were the risk factors for conversion to laparotomy (P < 0.001). A score >3 points was associated with a high risk of conversion to laparotomy. Conclusions The LC scoring system and surgical grading management are reliable and effective tools for predicting and reducing the conversion rate of LC to laparotomy.

Key words: Laparoscopy, Cholecystectomy, Conversion to laparotomy, Risk factor, Scoring system

中图分类号:

张男男, 郭金星, 吴钢, 易辉, 周远航, 廖芝伟, 黄琦, 董建. 腹腔镜胆囊切除术中转开腹评估体系的建立及手术分级管理探索[J]. 外科理论与实践, 2025, 30(01): 54-60.

ZHANG Nannan, GUO Jinxing, WU Gang, YI Hui, ZHOU Yuanhang, LIAO Zhiwei, HUANG Qi, DONG Jian. Establishment of an evaluation system for conversion to laparotomy in laparoscopic cholecystectomy and exploration of surgical grading management[J]. Journal of Surgery Concepts & Practice, 2025, 30(01): 54-60.

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Characteristic		LC group (n=9 246)	Transfer laparotomy group（n=168）	χ² value	P value
Gender: male		4 186（45.3）	69（41.1）	1.176	0.278
Age ≥ 65 years		2 192（23.7）	41（24.4）	0.044	0.833
BMI≥ 28 kg/m²		280（3.0）	6（3.6）	0.165	0.684
Diabetes		325（3.5）	10（6.0）	2.856	0.091
History of upper abdominal surgery		564（6.1）	15（8.9）	2.287	0.130
Body temperature≥38.5℃		1 524（16.5）	105（62.5）	244.173	<0.001
Murphy sign positive		2 775（30.0）	110（65.5）	97.634	<0.001
Frequency of acute cholecystitis ≥3 times		3 246（35.1）	96（57.1）	34.991	<0.001
Duration of acute cholecystitis ≤72 h		3 452（37.3）	68（40.5）	0.695	0.404
Total bilirubin ≥23 μmolL		1 235（13.4）	58（34.5）	62.393	<0.001
Maximum cross-section of gallbladder ≥5 cm×10 cm or ≤ 3 cm×4 cm		1 975（21.4）	32（19.0）	0.526	0.468
Maximum thickness of gallbladder wall ≥5 mm		1 885（20.4）	72（42.9）	50.593	<0.001
Gallbladder neck stone incarceration		1 025（11.1）	60（35.7）	98.149	<0.001
Diameter of common bile duct ≥8 mm		725（7.8）	62（36.9）	181.928	<0.001
Surgical experience	≤50 cases	835（9.0）	78（46.4）	280.787	<0.001
	51-200 cases	2 864（31.0）	55（32.7）
	>200 cases	5 547（60.0）	35（20.8）

Characteristic		Regression coefficient	Wald χ²	P value	OR	95% CI
Body temperature≥38.5℃		1.578	72.113	<0.001	4.847	3.367-6.978
Frequency of acute cholecystitis ≥3 times		0.754	19.266	<0.001	2.125	1.518-2.976
Maximum thickness of gallbladder wall ≥5 mm		1.195	46.175	<0.001	3.305	2.341-4.666
Gallbladder neck stone incarceration		1.667	76.388	<0.001	5.297	3.645-7.698
Diameter of common bile duct ≥8 mm		1.858	98.958	<0.001	6.414	4.447-9.249
Surgical experience	≤50 cases	2.09	80.443	<0.001	8.088	1.816-4.419
	51-200 cases	1.041	21.077	<0.001	2.833	5.122-12.771

Evaluate project		Scores
Body temperature≥38.5℃		1.5
Frequency of acute cholecystitis ≥3 times		0.5
Maximum thickness of gallbladder wall ≥5 mm		1
Gallbladder neck stone incarceration		1.5
Diameter of common bile duct ≥8 mm		2
Surgical experience	>200 cases	0
	51-200 cases	1
	≤50 cases	2

Surgical experience Objective factor scale evaluation score: X	X>3	2<X≤3	1<X≤2	X≤1
≤50 cases	high-risk	high-risk	high-risk	LC
51-200 cases	high-risk	high-risk	LC	LC
>200 cases	high-risk	LC	LC	LC

Item	Before use	After use	χ² value	P value
LC cases	9 414	620
Direct laparotomy	0	15
Conversion to laparotomy	168(1.78)	4(0.65)	4.482	<0.05