Ryuzo Murai

Ultrasonographic assessment of the risk of injury to branches of the middle hepatic vein during laparoscopic cholecystectomy

BACKGROUND Although hemorrhage from the gallbladder bed during laparoscopic cholecystectomy is one of main reasons for conversion to open cholecystectomy, the cause of this life-threatening complication is unclear. PATIENTS AND METHODS Color Doppler ultrasound was used to examine the cause of venous hemorrhage from the gallbladder bed during laparoscopic cholecystectomy in 4 patients postoperatively and to examine the anatomic relationship between the gallbladder bed and branches of the middle hepatic vein in 50 healthy volunteers. RESULTS Injury to a large branch of the middle hepatic vein adjacent to the gallbladder bed was diagnosed in all 4 patients. One patient required conversion to open cholecystectomy while the bleeding in 2 patients was immediately controlled by direct pressure with the gallbladder. The branch of the middle hepatic vein was completely adherent to the gallbladder bed in 5 of the 50 volunteers, and in 1 the diameter of the branch was as large as 3.5 mm. In 3 volunteers branches 3.0 to 3.8 mm in diameter traversed as close as 1.0 mm from the gallbladder bed. CONCLUSIONS Patients with large branches of the middle hepatic vein close to the gallbladder bed are at risk of hemorrhage during laparoscopic cholecystectomy and should be identified preoperatively with ultrasound.

Percutaneous stenting for malignant biliary stenosis.

SummaryPercutaneous stenting for malignant biliary stenosis is quite beneficial to patients with unresectable or recurrent disease, tremendously improving the quality of their lives. Percutaneous transhepatic biliary drainage (PTBD) was attempted in 92 patients with obstructive jaundice during the period between January 1986 and July 1989. Implantation of an endoprosthesis was performed in 14 cases (15.2%) and succeeded in 12 (85.7%). When a guide wire could not be passed distally across the stricture site, percutaneous transhepatic cholangioscopy (PTCS) through the dilated PTBD fistula was carried out to enable its passage. PTCS is also valuable in the preoperative diagnosis of obstructive jaundice. The patients who are not candidates for surgery are suitable for this procedure. A Miller double-mushroom stent is used as the endoprosthesis in the majority of cases. One patient with recurrent hepatoma has lived at home with this stent for >3 years due to repeated transarterial embolization and chemotherapy and does not need to wash or change the stent.

Laparoscopic cholecystectomy with an ultrasound surgical aspirator

Laparoscopic cholecystectomy using an ultrasound surgical aspirator has been performed in our department since March 1991. The horn cover was altered in order to be inserted through a trocar 10 mm in diameter. The main purpose of this device is to explore Calots triangle by fragmentation and aspiration of the fatty tissue without damaging the nerves, vessels, and cystic duct. First the serosa of the Calots triangle is cut via electrocautery with the sharp-angle hook dissector we designed. Then the cystic duct and cystic artery are efficiently exposed by the ultrasound surgical aspirator. This procedure is perfectly adapted for laparoscopic cholecystectomy. We obtained favorable results with the ultrasound surgical aspirator in 135 cases including 40 cases with a negative gallbladder, as evaluated by endoscopic retrograde cholangiography. In conclusion, the ultrasound surgical aspirator is suitable for skeletonizing the cystic duct and cystic artery, and the procedure is perfectly safe.

A Case of Glomus Tumor of the Stomach Resected by Laparoscopic Surgery - A Case Report.

症例は62歳の男性. 検診の上部消化管造影検査の際胃の異常陰影を指摘され当院外来を受診した. 身体所見, 血液検査では異常所見は認められなかった. 上部消化管造影検査では幽門前庭部小彎に2.5cm大の立ち上がりなだらかで表面平滑な隆起性病変を認め, 超音波内視鏡検査 (EUS) では筋層内の均一な低エコーの腫瘍と描出され, 胃平滑筋腫の疑いと診断された. 生検ではGroup 1であった. 確定診断と治療を兼ね腹腔鏡下胃部分切除術を行った. 病理組織学的には腫瘍細胞は固有筋層内に存在し, 卵円形, 均一で広い胞体を有し胃glomus腫瘍と診断した.胃glomus腫瘍は1962年に本邦で初めて報告されて以来69例しか報告例のないまれな疾患である. 腹腔鏡下に切除した報告例は過去1例だけであるが, 良性腫瘍である胃glomus腫瘍に対する治療法としては腹腔鏡下胃部分切除が妥当であると考える.

Patients' Recognition on the Laparoscopic Cholecystectomy. Propriety of Switching to the Day-care Surgery.

今後, day surgery(DS)への移行が予測される腹腔鏡下胆曩摘出術(LC)施行患者の意識調査を施行した. 希望入院時期は術前日: 55%, 2～3日前: 43%, 術当日: 2%であり, また当日入院は忙しさよりも個々の価値観から派生すると考えられた. 83%以上が入院期間延長による負担増額を気にせず入院していた. 民間の保障制度には80%が加入し, うち86%が請求していた. 術後入院期間短縮を考慮する負担増額は1万円/日程度と思われた. 術後入院期間は全例で4.5±1.9日, 非常に多忙, 多忙, やや余裕あり, 余裕ありそれぞれ3.7±0.8, 4.3±1.9, 4.5±1.9, 5.2±2.0日で, 余裕のある者で有意に長かった. しかし体験した程度でよいとする者が87%を占め, 短縮希望者は8%に止まった. うち自己負担額の増域によらず積極的に早期退院を望む者は全体の3%に過ぎなかった. 現行医療保険制度内では, 本調査施行患者はLCのDS化にあらゆる面で肯定的とは考えられなかった.