“十字坐标线定位法”在腹腔镜胆囊切除术中的应用体会

doi:10.16139/j.1007-9610.2025.05.07

摘要/Abstract

摘要：

目的： 探讨以“十字坐标线定位法”为基础实现关键性安全视野(CVS)在腹腔镜胆囊切除术(LC)中的应用体会。方法： 选择2020年2月—2023年2月在上海交通大学医学院附属瑞金医院无锡分院接受“十字坐标线定位法”治疗的84例病人作为观察组，并随机抽取同期接受传统LC治疗的84例病人作为对照组。观察组采用“十字坐标线定位法”为界限标识，达成CVS、完成胆囊切除；对照组采用传统钝、锐结合操作方法游离胆囊三角并解剖出胆囊管和胆囊动脉逐一结扎离断。对比分析两组术中、术后及相关并发症发生情况。结果： 168例病人均顺利完成LC，无严重手术并发症和中转开腹病例。观察组手术用时长于对照组[(89.5±12.3) min 比(67.7±8.9) min，P<0.001），术中出血量少于对照组[(7.0±3.9) mL比(15.2±4.6) mL， P<0.001）。观察组胆道、血管变异发现率高于对照组（9.5%比1.2%，P=0.040）。观察组术后第一天活动能力高于对照组，术后首次进食时间、术后首次排气时间均早于对照组（P<0.05）。观察组术后并发症总发生率低于对照组（2.4%比10.7%, P=0.029）。两组引流管放置例数、住院天数差异无统计学意义（P>0.05）。结论： “十字坐标线定位法”以其恒定的解剖位置作为基础标志，可帮助手术医师快速锁定安全操作区域、实现胆囊三角CVS以避免胆管损伤、降低相关并发症的发生率。

关键词: 腹腔镜胆囊切除术, Rouviere沟, 关键性安全视野, 胆囊三角, 胆管损伤

Abstract:

Objective To explore the application of the “cross-shaped coordinate line localization method” in laparoscopic cholecystectomy (LC) to realize critical view of safety (CVS) as well as summarize its safety and practicality. Methods Eighty-four patients who were treated with the “cross-shaped coordinate line localization method” at the Department of General Surgery of Wuxi Branch of Ruijin Hospital, Shanghai Jiao Tong University School of Medicine from February 2020 to February 2023 were selected as the observation group, and 84 patients who were randomly selected to receive the traditional LC treatment during the same period were selected as the control group. In the observation group, the “cross-shaped coordinate line localization method” was used as the boundary mark to reach CVS, and complete cholecystectomy. In the control group, the traditional blunt and sharp operation methods were used to free gallbladder triangle, and dissect out the cystic ducts and cystic arteries one by one and ligate them off. The intraoperative, postoperative and related complications of the two groups were compared and analyzed. Results All 168 patients successfully completed LC without serious surgical complications or conversion to open cases. The observation group took longer operation time to than the control group [(89.5±12.3) min vs. (67.7±8.9) min, P<0.001), and intraoperative blood loss was less than the control group [(7.0±3.9) mL vs. (15.2±4.6) mL, P<0.001). The rate of biliary and vascular anomalies in the observation group was higher than that in the control group (9.5% vs. 1.2%, P=0.040). The observation group had higher mobility on the first postoperative day than the control group, and time to first postoperative feeding and time to first postoperative flatus were earlier than those of the control group (P<0.05). The overall incidence rate of related complications in the observation group was lower than that in the control group (2.4% vs. 10.7%, P=0.029). There was no statistically significant difference between the two groups in terms of drain placement and length of hospital stay (P>0.05). Conclusions The “cross-shaped coordinate line localization method”, with its constant anatomical position as the basic symbol, can help surgeons quickly lock the safe operation area and realize CVS of the gallbladder triangle to avoid bile duct injury and reduce the incidence of related complications.

Key words: Laparoscopic cholecystectomy(LC), Rouviere sulcus, Critical view of safety(CVS), Gallbladder triangle

中图分类号:

R657.4

梁勇, 孙晶, 吴卫泽. “十字坐标线定位法”在腹腔镜胆囊切除术中的应用体会[J]. 外科理论与实践, 2025, 30(05): 417-422.

LIANG Yong, SUN Jing, WU Weize. Application experience of the cross-shaped coordinate line localization method in laparoscopic cholecystectomy[J]. Journal of Surgery Concepts & Practice, 2025, 30(05): 417-422.

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参考文献 20

[1]	LÜNSE S, HEIDECKE C D, PARTECKE L I. Laparoskopische cholezystektomie[J]. Zentralbl Chir, 2022, 147(4):338-342. doi: 10.1055/a-1546-2709 URL
[2]	中华医学会外科学分会胆道外科学组, 中国医师协会外科医师分会胆道外科医师委员会. 胆囊良性疾病外科治疗的专家共识(2021版)[J]. 中华外科杂志, 2022, 60(1):4-9.
	Branch of Biliary Surgery, Chinese Society of Surgery, Chinese Medical Association, Chinese Medical Doctor Association in Chinese Committee of Biliary Surgeons. Consensus on the surgical management of benign gallbladder diseases (2021 edition)[J]. Chin J Surg, 2022, 60(1):4-9.
[3]	HUGH T B, KELLY M D, MEKISIC A. Rouvière’s sulcus: a useful landmark in laparoscopic cholecystectomy[J]. Br J Surg, 1997, 84(9):1253-1254.
[4]	张硕, 杨军, 顾元龙. 腹腔镜胆囊切除术致胆道损伤的危险因素及处理[J]. 中华肝脏外科手术学电子杂志, 2021, 10(5):470-473.
	ZHANG S, YANG J, GU Y L. Risk factors and management of bile duct injury caused by laparoscopic cholecystectomy[J]. Chin J Hepat Surg(electronic edition), 2021, 10(5):470-473.
[5]	WONG H J, KOJIMA Y, SU B, et al. Long-term retention after structured curriculum on attainment of critical view of safety during laparoscopic cholecystectomy for surgeons[J]. Surgery, 2022, 171(3):577-583. doi: 10.1016/j.surg.2021.08.063 URL
[6]	何旭昶, 安文慧, 陈洋伟, 等. 安全术野技术的历史沿革及发展现状[J]. 肝胆胰外科杂志, 2023, 35(10):638-640,封3.
	HE X C, AN W H, CHEN Y W, et al. Historical evolution and current development of safe surgical field technology[J]. J Hepatopancreatobiliary Surg, 2023, 35(10):638-640, cover 3.
[7]	ADRALES G, ARDITO F, CHOWBEY P, et al. A multi-national, video-based qualitative study to refine training guidelines for assigning an “unsafe” score in laparoscopic cholecystectomy critical view of safety[J]. Surg Endosc, 2024, 38(2):983-991. doi: 10.1007/s00464-023-10528-6
[8]	GAD E H, AYOUP E, KAMEL Y, et al. Surgical management of laparoscopic cholecystectomy (LC) related major bile duct injuries; predictors of short-and long-term outcomes in a tertiary Egyptian center - a retrospective cohort study[J]. Ann Med Surg (Lond), 2018,36:219-230.
[9]	WAKABAYASHI G, TAKADA T. Response to the comment on "Tokyo guidelines 2018: surgical management of acute cholecystitis: safe steps in laparoscopic cholecystectomy for acute cholecystitis (with videos)"[J]. J Hepatobiliary Pancreat Sci, 2020, 27(11):e19. doi: 10.1002/jhbp.851 pmid: 33156980
[10]	闫加艳, 赵越, 陈炜. 国际《胆囊切除术中预防胆管损伤多协会共识和实践指南(2020)》解读[J]. 中国实用外科杂志, 2020, 40(12):1391-1395,1400. doi: 10.19538/j.cjps.issn1005-2208.2020.12.14
	YAN J Y, ZHAO Y, CHEN W. Interpretation of the international multi-society consensus and practice guidelines for prevention of bile duct injury during cholecystectomy (2020)[J]. Chin J Pract Surg, 2020, 40(12):1391-1395,1400.
[11]	王勇, 沈攀峰, 朱稳, 等. CVS理念在有腹部手术史患者行急诊腹腔镜胆囊切除中的应用体会[J]. 肝胆外科杂志, 2023, 31(3):205-208.
	WANG Y, SHEN P F, ZHU W, et al. Experience with the application of the critical view of safety (CVS) concept in emergency laparoscopic cholecystectomy for patients with a history of abdominal surgery[J]. J Hepatobiliary Surg, 2023, 31(3):205-208.
[12]	胡金龙, 李敏, 刘东全, 等. 回溯手术评估安全性关键术野技术在LC中的应用价值[J]. 重庆医学, 2022, 51(15):2609-2613.
	HU J L, LI M, LIU D Q, et al. Clinical value of the critical view of safety (CVS) technique in laparoscopic cholecystectomy: a retrospective surgical evaluation[J]. Chongqin Med J, 2022, 51(15):2609-2613.
[13]	IBRARULLAH M, MOHANTY L, MISHRA A, et al. Anatomical appraisal of safe cholecystectomy: a prospective study[J]. ANZ J Surg, 2023, 93(5):1329-1334. doi: 10.1111/ans.18387 pmid: 36921100
[14]	宫路路, 王赈霄, 杨永生, 等. Rouviere沟在腹腔镜胆囊切除术中意义的再评估[J]. 腹腔镜外科杂志, 2019, 24(6):478-480.
	GONG L L, WANG Z X, YANG Y S, et al. Re-evaluation of the significance of Rouviere’s sulcus in laparoscopic cholecystectomy[J]. J Laparosc Surg, 2019, 24(6):478-480.
[15]	胡秋石, 张磊, 赵沨, 等. R4U平面区域划分LC与壶腹部技术LC临床疗效对比[J]. 肝胆胰外科杂志, 2022, 34(12):735-738.
	HU Q S, ZHANG L, ZHAO F, et al. Comparison of clinical outcomes between R4U plane-based and ampullary techniques in laparoscopic cholecystectomy[J]. J Hepatopancreatobiliary Surg, 2022, 34(12):735-738.
[16]	胡小强, 潘敏, 汪剑良, 等. Rouviere沟引导下腹腔镜胆囊切除术40例[J]. 肝胆胰外科杂志, 2020, 32(11):695-697.
	HU X Q, PAN M, WANG J L, et al. Laparoscopic cholecystectomy under the guidance of Rouviere’s sulcus: a report of 40 cases[J]. J Hepatopancreatobiliary Surg, 2020, 32(11):695-697.
[17]	BASUKALA S, THAPA N, TAMANG A, et al. Rouviere’s sulcus - an anatomical landmark for safe laparoscopic cholecystectomy: a cross-sectional study[J]. Ann Med Surg (Lond), 2022,75:103404.
[18]	DHANASEKARA C S, SHRESTHA K, GROSSMAN H, et al. A comparison of outcomes including bile duct injury of subtotal cholecystectomy versus open total cholecystectomy as bailout procedures for severe cholecystitis: a multicenter real-world study[J]. Surgery, 2024, 176(3):605-613. doi: 10.1016/j.surg.2024.03.057 URL
[19]	杨少华, 胡晟, 洪茂林, 等. 中国腹腔镜胆囊切除胆管损伤危险因素的荟萃分析[J]. 中国现代普通外科进展, 2022, 25(9):694-701.
	YANG S H, HU S, HONG M L, et al. Risk factors for bile duct injury in laparoscopic cholecystectomy in China: a meta-analysis[J]. Chin J Curr Adv Gen Surg, 2022, 25(9):694-701.
[20]	ORD J R, KRISCHAK M K, SHAH J A, et al. Duct of Luschka bile leak following deceased donor liver transplant[J]. Am J Case Rep, 2021,22:e933505.

Item	Observation group	Control group	t/χ² value	P value
Operation time(min)	89.5±12.3	67.7±8.9	t=13.135	<0.001
Intraoperative blood loss(mL)	7.0±3.9	15.2±4.6	t=12.273	<0.001
Biliary and vascular anomalies	8(9.5)	1(1.2)	χ²=4.226	0.040
Drain placement	26(31.0)	24(28.6)	χ²=0.114	0.736

Item	Observation group	Control group	t value	P value
Barthel index	84.2±5.1	71.3±3.2	19.401	<0.001
Time to first postoperative feeding（h）	9.2±3.6	15.7±2.8	12.919	<0.001
Time to first postoperative flatus（h）	14.1±4.0	18.6±2.8	8.348	<0.001
Length of hospital stay（d）	3.6±1.0	4.0±1.5	1.869	0.063

Item	Observation group	Control group	χ² value	P value
Postoperative bleeding	0	1(1.2)	-	1.000
Postoperative bile leakage	0	0	-	-
Surgical site infection	1(1.2)	4(4.8)	-	0.367
Intra-abdominal infection	1(1.2)	4(4.8)	-	0.367
Overall incidence rate	2(2.4)	9(10.7)	4.767	0.029