腹腔粘连患者腹腔镜胆囊切除术闭合法建立气腹

目的 探讨腹腔粘连患者腹腔镜胆囊切除术（LC）闭合法建立气腹的方法。方法 回顾性分析1991年9月－1999年9月6600例LC中1046例腹腔粘连患者闭合法建立气腹的经过。建立气腹困难分为真性建立气腹困难及假性建立气腹困难2种。由于气腹针穿入腹腔脏器或腹腔广泛粘连导致气体弥散困难引起的建立气腹困难称真性建立气腹困难,需中转开腹手术;由于气腹针位置错误如位于腹膜外脂肪层、肝园韧带或大网膜内引起的建立气腹困难称假性建立气腹困难,调整气腹针位置,均能满意建立气腹。结果 1046例中1028例成功建立气腹。5例因真性建立气腹困难,13例因假性建立气腹困难而中转开腹。本组腹腔粘连患者闭合法建立气腹成功率为98．3％。结论 腹腔粘连患者闭合法建立气腹是安全可行的。缺乏自信、经验不足、误把假性建立气腹困难当作真性建立气腹困难是腹腔粘连患者闭合法建立气腹失败的主要原因。     

有腹部手术史患者腹腔镜术闭合法建立气腹方法探讨

目的 探讨有腹部手术史患者腹腔镜术闭合法建立气腹的可行性及操作方法。方法 回顾分析我院１９９１年９月至１９９８年１２月６２００例腹腔镜术中９６３例有腹部手术史患者闭合法建立气腹成功的经验及２例内脏损伤的教训；我们把建立气腹困难分为真性建立气腹困难及假性建立气腹困难两种。由气腹针穿入大网膜、肝圆韧带、肠系膜、腹膜外脂肪等引起的充气困难称假性建立气腹困难，而因气腹针穿入腹腔脏器（如胃肠道、大血管）或因腹腔内存在广泛粘连致气体膨胀困难引起撤气困难称为真性建立气腹困难。结果 ６例患者因真性建立气腹困难、１２例因假性建立气腹困难而中转开腹，闭合法建立气腹成功率为９８％。２例胆囊结石虱因未遵循闭合法建立气腹原则致空肠或回肠损伤，立即开腹行肠修补、胆囊切除术。结论 绝大多数有腹部手术史患者闭合法建立气腹是安全可行的。遵循闭合     

半开放置鞘气腹法在腹部手术史患者腹腔镜术中的应用

目的　探讨腹腔镜术半开放置鞘气腹法对有腹部手术史患者建立气腹的可行性及操作方法。　方法　回顾分析 1994年 10月～ 2 0 0 2年 1月 2 10 0例腹腔镜术中 117例有腹部手术史患者半开放置鞘气腹法 115例成功的经验及 2例失败的教训。　结果　 117例中 115例成功建立气腹 ,1例胃大部切除术后胆囊结石反复穿刺导致空肠穿孔 ,腹腔镜下行空肠修补术和腹腔镜胆囊切除术 ,1例剖宫产术后因腹腔内广泛粘连气体膨胀困难而中转开腹。本组半开放置鞘气腹法成功率 98 3 % (115 / 117)。　结论　有腹部手术史患者半开放置鞘气腹法建立气腹安全可行 ,融合闭合法及开放法的优点 ,操作简便。     

胃十二指肠手术史患者的腹腔镜胆囊切除术

目的 :探讨有胃十二指肠手术史患者行腹腔镜胆囊切除术的可行性及疗效。方法 :回顾分析有胃十二指肠手术史 86例的腹腔镜胆囊切除术手术过程。结果 :气腹建立困难 8例 ,腹腔严重粘连无法分离 7例 ,胆囊周围粘连包括Calot三角粘连分离困难 4例均行中转开腹手术。第 1孔穿刺损伤肠管 2例 ,分离粘连时损伤肠管 1例 ,均在腹腔镜下修补。结论 :胃十二指肠手术后腹腔内严重粘连是气腹建立困难或腹腔粘连分离困难而中转开腹的主要原因。第 1孔穿刺肠管损伤和腹腔粘连分离肠管损伤发生率较高。严格掌握手术适应证 ,腹腔镜操作技术娴熟是手术成功的关键     

腹腔镜手术半开放置鞘气腹法安全建立气腹5 598例分析

目的:探讨腹腔镜手术半开放置鞘气腹法建立气腹的可行性及操作方法。方法:回顾分析5 600例腹腔镜术中半开放置鞘气腹法5 598例成功的经验及2例失败的教训。结果:5 600例中5 598例成功建立气腹,1例胃大部切除术后胆囊结石反复穿刺导致空肠穿孔,腹腔镜下行空肠修补术和腹腔镜胆囊切除术;1例剖宫产术后因腹腔内广泛粘连,气体膨胀困难而中转开腹。本组半开放置鞘气腹法成功率为99.96%。结论:半开放置鞘气腹法融合闭合法及开放法的优点,安全可行,操作简便。     

单孔腹腔镜胆囊切除术在有腹部手术史患者中的应用

目的:探讨Hasson法建立气腹行单孔腹腔镜胆囊切除术在有腹部手术史患者中的应用优势及操作技巧。方法:回顾分析2011年11月至2018年10月为117例合并腹部手术史患者行单孔腹腔镜胆囊切除术的临床体会。结果:113例成功完成手术,4例因腹腔内粘连严重无法显露术野及胆囊三角中转开腹,成功率96.6%。术后患者恢复良好,切口美观隐蔽,无网膜损伤及相关并发症发生。结论:Hasson法建立气腹行单孔腹腔镜胆囊切除术,可灵活选取切口部位直视下开腹,避免了粘连肠管网膜的损伤,有效松解腹腔粘连带,对于有腹部手术史的胆囊良性疾病患者是安全、可行、微创、美观的治疗选择。     

有腹部手术史病人的腹腔镜胆囊切除术

目的　对因开腹手术而造成腹腔粘连的病人实施腹腔镜胆囊切除术 (Laparoscopiccholecystectomy ,LC)的可行性及手术方法进行探讨。 方法　对 5 6 0例LC术中的 5 0例有开腹手术史的病人进行分析讨论。结果　 5 0例中有 4 5例成功完成LC术 ,5例因粘连严重或建立气腹困难而中转开腹手术 ,术后均恢复良好 ,无严重并发症出现。结论　开腹手术后再行LC术是完全可行的。     

腹腔镜手术穿刺建立气腹损伤脏器的预防

我院 1995～ 2 0 0 2年 7年中共进行了腹腔镜手术 15 0 0例 ,发生穿刺建立气腹时损伤腹腔脏器 5例 ,报告如下。临床资料我院进行的腹腔镜手术 15 0 0例 ,均是采取 Veress针穿刺建立气腹 ,绝大部分病例是在全麻下进行。总共发生 5例于穿刺建立气腹时损伤腹腔脏器 ,4例损伤大网膜或肠系膜血管的病例 ,1例因出血而中转开腹予以处理 ,另 3例均于腹腔镜中钳夹出血点予以处理 ;1例损伤肠壁 ,被迫中转开腹处理。腹腔镜手术穿刺建立气腹损伤脏器的比例为 0 .33%。另外 5例中有 3例是在用 Vesress针穿刺建立气腹时 ,病人的麻醉深度不够 ,腹肌突然收…     

腹部手术史对妇科腹腔镜手术影响的对比研究

目的探讨有腹部手术史患者行妇科腹腔镜手术的可行性和安全性。方法回顾性分析我院1998年2月～2005年10月有腹部手术史的178例行妇科腹腔镜手术的临床资料,并随机（随机数字表法）选择同期无腹部手术史的180例作为对照,以评价腹部手术史对气腹建立、中转开腹和并发症的影响。结果手术史组176例气腹形成和第一trocar穿刺顺利,2例肥胖病人腹壁过厚导致腹膜外充气,改为开放法建立气腹;对照组177例气腹形成和第一trocar穿刺顺利,1例肥胖病人腹膜外充气,改为开放法建立气腹,2例“腹茧症”气腹不能形成中转开腹手术。手术史组腹腔粘连68例（38.2%）,对照组腹腔粘连17例（9.4%）,两组差异有显著性（χ^2=40.879,P=0.000）。手术史组20例（11.2%）中转开腹手术,发生9例（5.1%）并发症,其中2例脏器损伤;对照组16例（8.9%）中转开腹手术,发生7例（3.9%）并发症,其中1例脏器损伤。两组中转开腹手术率和并发症发生率差异无显著性（χ^2=0.545,P=0.460;χ^2=0.286,P=0.593）。结论对有腹部手术史患者,根据前次手术的类型和手术切口的位置,选择合适的穿刺顺序,行妇科腹腔镜手术是安全、可行的。勿需改变传统的穿刺孔位置。     

低压气腹腹腔镜胆囊切除术在高危胆囊结石患者中的应用

目的 探讨高危人群低压气腹下腹腔镜胆囊切除术的安全性。方法 回顾分析近3年来对72例高危人群低压气腹下用腹腔镜行胆囊切除术的临床资料。结果 72例中,因术中出血中转开腹1例,因粘连分离困难开腹2例,余均顺利完成手术,无手术并发症,无死亡。结论 高危人群合并胆囊结石选用腹腔镜行胆囊切除术是安全、有效、可靠的方法,术后并发症少。低压缓慢造气腹是行腹腔镜胆囊切除术成功的关键。     

Safety of the Veress needle in pediatric laparoscopy

PURPOSE: To better establish the complication rate with the Veress needle technique for establishing a pneumoperitoneum in pediatric laparoscopy. PATIENTS AND METHODS: We reviewed all pediatric laparoscopy cases performed by a single surgeon from 1996 to 2003. There were 257 patients ranging in age from 4 months to 19 years. Infraumbilical placement of the Veress needle was used to create a pneumoperitoneum. All instances of preperitoneal insufflation, vessel/viscus injury, and forced conversion to open surgery were recorded. The length of time required to establish pneumoperitoneum was reported in the last 139 patients. RESULTS: The average length of time required to gain access to the peritoneum was <2 minutes. Of these procedures, 138 were performed for nonpalpable undescended testicles, 101 for varicoceles, 13 for duplication anomalies, and 5 for intersex disorders. There were 18 cases (7.0%) of preperitoneal insufflation. No cases resulted in vessel/visceral injury, conversion to open surgery, conversion to use of the Hassan trocar technique, or inability to complete the procedure because of complications in establishing a pneumoperitoneum. In all cases of preperitoneal insufflation, proper access was achieved by pulling the needle out and reinserting it at a different angle, with pneumoperitoneum being achieved easily in each case. CONCLUSION: The use of the Veress needle to establish pneumoperitoneum in children of all ages is safe, fast, and efficacious.     

腹腔镜手术治疗剖宫产术后子宫瘢痕部位妊娠

目的探讨剖宫产术后子宫瘢痕部位妊娠（caesarean scar pregnancy,CSP）腹腔镜手术治疗的价值。方法采用全身麻醉,膀胱截石位,气腹针穿刺进腹,腹腔充CO2气体（压力13 mm Hg）,置入trocar,进镜探查。分离子宫前壁峡部与周围组织的粘连,电切打开膀胱子宫反折腹膜,下推膀胱。子宫下段宫壁肌注垂体后叶素6 U,单极电钩楔形切除病灶组织,1号薇乔线连续双层缝合子宫肌层。结果 13例CSP行腹腔镜下病灶切除术联合子宫修补术。术后住院3~5 d。13例术后1~3周后血β-hCG降至正常,1~2个月月经恢复正常。结论腹腔镜手术治疗子宫瘢痕部位妊娠效果确切,疗效好,恢复快。     

Vascular complications during laparoscopy. An analysis of a personal case]

Vascular complications of laparoscopy most often occur during Veress needle or primary trocar placement. Veress needle punctures are insignificant and require no further treatment, whereas trocar induced vascular injuries can be catastrophic. The frequency of vascular or viscus injuries is difficult to calculate since several complications are not published. A vascular complication occurred in a young girl with neurologic problems and a kyphoscoliosis operated on in laparoscopy for a gastroesophageal reflux is discussed. After the establishment of pneumoperitoneum, an important hemoperitoneum was rapidly evident at insertion of the laparoscope. An open laparotomy was performed showing right common iliac vessel injuries and several intestinal perforations. After a complex vascular reconstruction and a multiple intestinal suture, the Nissen fundoplication with pyloroplasty was performed traditionally and the patient leave the hospital free of symptoms after 20 days. In laparoscopy, as in all areas of surgery, experience knowledge and meticulous attention to details are the most important factors in order to avoid complications. The authors believe that the open approach with Hasson cannula is the most important factor in avoiding complications.     

A safe and simple method for routine open access in laparoscopic procedures

Background: Access to the peritoneal cavity in laparoscopic procedures is generally achieved by means of a pneumoperitoneum, following introduction of a Veress needle. Because this procedure must be done blindly, it is not without visceral or vascular hazards. Therefore, we sought an alternative technique that might obviate these complications. Methods: In a series of 803 patients, a modified Hasson technique was used to obtain a pneumoperitoneum without risking the complications associated with the introduction of a Veress needle. Results: The modified Hasson technique proved to be feasible in all cases. No visceral or vascular complications resulted, but 10 patients had a transient serous discharge. Follow-up ranged between 5 and 52 months. Conclusion: The modified Hasson technique should always be used in laparoscopic procedures. Received: 17 December 1997/Accepted: 7 May 1998     

妇科腹腔镜改良开放穿刺法的随机对照研究

目的:比较初学者使用第一枚Trocar直接穿刺和传统气腹针穿刺两种方法建立气腹的学习曲线和并发症发生率,探讨第一枚Trocar直接穿刺的安全性、有效性和实用性。方法:随机将2009年7月至2009年12月入院接受腹腔镜手术的100例患者分为A、B两组,A组用改良的开放穿刺法,即切开脐孔筋膜或切开脐孔,直接穿刺第一枚Trocar,B组用传统的气腹针穿刺法,气腹形成后穿刺Trocar,分析两种方法的并发症发生率和术者的学习曲线。结果:两组穿刺成功率差异无统计学意义(χ2=2.743,P=0.098),均无大血管和器官损伤。A组的手术时间和并发症发生率优于B组(P0.05)。术者掌握A方法的学习曲线短于B方法。结论:用改良的开放穿刺法建立气腹有效、快捷、易学。培训初学者用此方法更安全。     

Induction of Pneumoperitoneum in Morbidly Obese Patients

Background: Induction of pneumoperitoneum can be a difficult, time-consuming, and occasionally hazardous task in a morbidly obese patient. Methods: We have induced pneumoperitoneum in 600 consecutive morbidly obese patients using a 120 mm Veress needle inserted <1 mm beneath the left costal margin, between the mid-clavicular and anterior axillary lines. Absolute muscular relaxation was necessary. Results: A distinct "pop" was felt on entering the peritoneal cavity. The expected intraperitoneal pressure was 7-14 mmHg. A pressure >20 mmHg indicated that the Veress needle was in the abdominal wall. CO2 infusion began at a flow of <1 L/min. "Shaking" the Veress needle to-and-fro improved flow to 1-2 L/min. Complete filling of the abdomen occurred at 4.0 L or more at a pressure limit of 15 mmHg. Increasing the pressure limit to 17 mmHg did not change the rate or final volume of CO₂ infusion. After initial trocar placement, the Veress needle was observed. Frequently it was in the omentum and there was CO₂ beneath the omentum. There was one visceral injury in the 600 patients - a puncture wound to the muscularis, but not the lumen, of the transverse colon. It was repaired laparoscopically with a single stitch. There have been no episodes of perforation of a hollow viscus, no unusual bleeding from the abdominal wall or viscera, and no injuries to the liver or spleen. Conclusion: Percutaneous induction of a pneumoperitoneum with the Veress needle in the left upper quadrant is a safe and effective technique in morbidly obese patients.     

The safety and efficacy of direct trocar insertion with elevation of the rectus sheath instead of the skin for pneumoperitoneum

Abdominal access in endoscopic surgery carries a finite risk of visceral injury. Bleeding, subcutaneous emphysema, gastrointestinal tract perforation, minor and major vascular injury, and intraperitoneal adhesions are the potential complications associated with abdominal access and creation of pneumoperitoneum. There are 4 basic techniques used to create pneumoperitoneum: blind Veress needle, direct trocar insertion, optical trocar insertion, and open laparoscopy. Veress needle and direct trocar insertion are blind techniques, and their use can result in severe visceral and vascular injuries. To prevent visceral and vascular injuries caused by the technique used for the creation of pneumoperitoneum, laparoscopic surgeons and gynecologists look for safe and effective laparoscopic access techniques. Direct trocar insertion without previous pneumoperitoneum was reported to be a safe alternative to Veress needle insertion. We carried out this study to compare the ease of use, safety, and efficacy of direct trocar insertion with elevation of the rectus sheath and blind insertion of the Veress needle in laparoscopic surgery. In 578 laparoscopic procedures, the patients were assigned to one of the following groups: blind insertion of the Veress needle (group 1, n = 301) and direct trocar insertion with elevation of the rectus sheath using 2 towel clips (group 2, n = 277). Total complication rates were 15.7% (n = 33) and 3.3% (n = 4) in groups 1 and 2, respectively (P < 0.05). Direct trocar insertion with elevation of the rectus sheath using 2 towel clips is an easy, safe, and effective technique.     

Trocar and Veress needle injuries during laparoscopy

Background: Inadvertent lesions of the intraabdominal organs and vessels caused by trocars and Veress needles are rare but serious complications of laparoscopic surgery. Establishing the pneumoperitoneum is believed to be the most dangerous step. Methods: The Swiss Association for Laparoscopic and Thoracoscopic Surgery (SALTS) prospectively collected the data on 14,243 patients undergoing various standard laparoscopic procedures between 1995 and 1997. This database was investigated with special regard to intraabdominal complications caused by trocars and Veress needles. Results: There were 22 trocar and four needle injuries (incidence, 0.18%). Nineteen lesions involved visceral organs; the remaining seven were vessel injuries. The small bowel was the single most affected organ (six cases), followed by the large bowel and the liver (three cases each). All vascular lesions, except for one laceration of the right iliac artery, occurred as venous bleeding of either the greater omentum or the mesentery. Fourteen trocars were inserted under direct vision. Nineteen trocar injuries were recognized intraoperatively; diagnoses of two small bowel and one bladder injuries were made postoperatively. Needle injuries were all diagnosed intraoperatively. Only five injuries could be repaired laparoscopically; the remaining lesions were repaired openly. Four patients underwent an open reoperation, and another patient needed five reoperations. There was one death (4.0%). Conclusions: Trocar and needle injuries are rare complications of laparoscopy. However, if not recognized intraoperatively and repaired immediately, they induce increased morbidity and mortality. Both open and closed establishment of the pneumoperitoneum are related to a potential danger of perforating lesions, but inserting the first trocar under direct vision allows early recognition and immediate repair.     

Our choice of the method to induce pneumoperitoneum in videolaparoscopic surgery

BACKGROUND: In laparoscopic surgery, pneumoperitoneum may be obtained either by a blind or an open access technique. These two techniques and the advantages of Hasson technique are compared. METHODS: Through January 1998 and May 1999, 262 unselected patients underwent laparoscopic surgery; pneumoperitoneum was obtained with a random technique, while in the patients previously operated on the open technique was always performed. In 161 cases (61.5%) pneumoperitoneum was obtained with Hasson technique and in 101 (38.5%) with Veress technique. All the patients were clinically evaluated after surgery and then after 30-40 days. The complications encountered were always associated with the Veress needle blind access: peritoneal space insufflation in 3 cases, greater omentum insufflation in 3 cases, 4 cases of difficult management and only one case of incisional hernia on the umbilical wound. RESULTS: Our data confirm that Hasson open technique is safer than Veress blind technique as the risk of severe early and late complications is lower. CONCLUSIONS: The open laparoscopic technique with the Hasson trocar is recommended as it showed to be a quicker, safer and superior technique for obtaining pneumoperitoneum.