腹腔鏡下胆嚢摘出術におけるレーザーメスの有用性

-総胆管結石砕石術も含めて-

抄録

Laparoscopic cholecystectomy (LC) has now become the first choice treatment for gallstones. Dissection of the gallbladder bed is importnat in performing the entire procedure successfully and several cutiting devices such as laser, electrocautery or harmonic scalpel are now applied. In the present study, the usefulness of laser for the dissection of gallbladder bed and lithotripsy of common bile duct stones was evaluated in 225 patients who had undergone LC and in 5 with common bile duct stones, respectively. Laser was used in 86 of the 225 patients, electrocautery, in 117, and harmonic scalpel in 22. Laser had effecient cutting and coagulation capabilities compared with the other two cutting devices, and it was consiedred to be an useful cutting device for LC. However, when the dissection layer was unclear, perforation of the gallbladder by laser occurred in 11 of 86 (12.8%), while electrocautery caused the perforation in 21 of 117 (18.0%), and harmonic scalpel, in 1 of 22 (0.5%). Although laser was considered to cause less tissue damage than electrocautery, its operation seemed rather difficult. In 5 patients with common bile duct stones, pulsed dye laser was used for lithotripsy. Laparoscopically, the cystic duct was exposed and a fine choledochoscope was inserted into the common bile duct through it. A fiber for laser guide was inserted through the scope into the bile duct and laser was fired at stones. In all the 5 patients, stones were smashed effectively. Small fragments of stones had disappeared completely during the operation in 1 patient, while some fragments still existed even after the procedure in the remaing 4. One of the 4 patinets had T-tube instituted by laparotomy and a tube wsa placed in the bile duct through the cystic duct (C-tube) in the remaing 3. In three of the 4 pateints, small stones disappered postoperatively and the other patient underwent endoscopic sphyncterotomy. Thus, laser was considered to be an important tool for not only the dissection of gallbladder bed but also lithotripsy of the common bile duct stones. However, improvement of the technique is necessary.