腹腔镜胆囊切除术电刀对局部肝组织热损伤的病理学光镜观察

目的：观察腹腔镜胆囊切除术（LC）电凝电切热损伤胆囊床局部肝组织的病理学变化。方法：取腹腔镜下电刀与剪刀（对照组）分别切除胆囊后胆囊床底部边缘肝组织1cm*1cm一块,每组各6例,标本立即浸入10％福尔马林液固定,石蜡包埋,连续横切片,光镜观察肝细胞的病理学变化。结果：剪切组（对照）各层肝细胞均正常,电切组浅层（1－4mm)肝细胞发生凝固性坏死及电热溶解,中层（5－8mm)肝细胞膜明显皱缩,肝血窦扩张,深层（9－10mm)肝细胞变性水肿,结论：LC术中电刀热损伤胆囊床局部肝组织呈外重内轻的病理学改变,深度可达1 cm。     

腹腔镜下电刀与剪刀切除胆囊术后血清ALT、AST水平变化的比较

目的研究腹腔镜胆囊切除术(LC)术后血清ALT、AST水平变化的原因.方法随机将1999年10月我院收治的69例胆囊结石患者分为A组35例,单极电刀切除胆囊,胆囊床普遍电凝处理,B组34例(对照组)剪刀切除胆囊,钛夹钳闭止血.手术结束时抽样取两组病人胆囊床底部边缘肝组织1cm×1cm一块,全部受试者术后1、5天抽血测定血清ALT、AST含量,数据均经统计学处理.结果A组(电切)术后1天血清ALT、AST水平显著升高,与B组(剪切)相比,差异有显著性意义(P＜0.01).肝活检标本病理组织学光镜观察,电刀接触面肝细胞发生电凝固性坏死,其内层肝细胞皱缩,深层(约1cm)肝细胞变性水肿;剪刀切除胆囊组肝细胞正常.结论LC术中电刀对局部肝组织热损伤是术后早期血清ALT、AST升高的主要原因.     

腹腔镜胆囊切除术肝脏病理与酶学变化的临床研究

目的 :研究腹腔镜胆囊切除术 (LC)肝脏病理与酶学变化的原因。方法 :将 1999至 2 0 0 1年我院收治的 6 9例胆囊结石随机分组 ,常规应用单极高频电刀行腹腔镜胆囊切除术 35例 (电切组 ) ,胆囊床普遍电凝处理 ;对照组应用剪刀行腹腔镜胆囊切除术 34例 (剪切组 ) ,钛夹钳闭止血 ;手术结束时每组抽样取 5例胆囊床底部边缘肝组织 1cm× 1cm ,病理切片 ,光镜观察肝细胞的变化 ,全部受试者术后 1～ 5d抽血测定血清ALT、AST含量 ,数据均经统计学处理。结果 :电切组术后 1d血清ALT、AST水平显著升高 ,与术前相比 ,差异有显著性 (P <0 .0 1) ,与剪切组术后相比 ,差异有显著性 (P <0 .0 1)。肝组织病理变化 ,电切组浅层 (电刀接触面 )肝细胞大部分热溶解坏死 ,其内层肝血窦扩散 ,肝细胞膜皱缩 ,深层 1cm处肝细胞变性水肿 ,剪切组肝细胞正常。结论 :LC术中单极高频电刀在密闭腔内对局部肝组织的热损伤是引起肝细胞坏死、皱缩、水肿等不同程度的病理变化的原因 ,深度可达 1cm ,是术后血清ALT、AST一过性升高的主要原因     

腹腔镜胆囊切除术中高频电刀对肝脏损伤的影响

目的　研究腹腔镜胆囊切除术肝脏病理与酶学变化的原因。方法　 1 999～ 2 0 0 1年我院收治的 6 9例胆囊结石随机分组。常规应用单极高频电刀行腹腔镜胆囊切除术 35例 (电切组 ) ,胆囊床普遍电凝处理 ;对照组应用剪刀行腹腔胆囊切除术 34例 (剪切组 ) ,钛夹钳闭止血 ;手术结束时每组抽样取 5例胆囊床底部边缘肝组织 1 cm× 1 cm一块 ,病理切片 ,光镜观察肝细胞的变化 ,全部受试者术后 1～ 5 d抽血测定血清 AL T、AST含量 ,数据均经统计学处理。结果　电切组术后 1 d血清AL T、AST水平显著升高 ,与术前相比 ,差异有显著性 (P<0 .0 1 ) ,与剪切组术后相比 ,差异有显著性 (P<0 .0 1 )。肝组织病理变化 ,电切组浅层 (电刀接触面 )肝细胞大部分热溶解坏死 ,其内层肝血窦扩散 ,肝细胞膜皱缩 ,深层 (1 cm )肝细胞变性水肿 ,剪切组肝细胞正常。结论　 L C术中单极高频电刀在密闭腔内对局部肝组织的热损伤是引起肝细胞坏死、皱缩、水肿等不同程度的病理变化 ,深度可达 1 cm ,是术后血清 AL T、AST一过性升高的主要原因     

Luschka胆管的外科意义

1863年Luschka首先描述一细长胆管,起自肝右叶胆囊窝,与右肝管或肝总管汇合。其直径为1～2mm,引流右后叶不同大小区域的亚段,排入右肝管或肝总管,偶尔至胆囊管。报道该管的发生率为1％至50％不等,该管所处的位置与胆囊切除术关系密切。作者介绍了20例尸解标本的结果和4例手术操作损伤Luschka胆管的防治经验。在30例尸解中,20例作了大体解剖,尤特别注意胆囊床和胆囊肝Calot三角区的解剖,另10例从胆囊床完整切取三大块组织,作石蜡切片。在20例大体解剖标本中,发现6例胆囊下胆管,其中5例位     

腹腔镜胆囊切除术后肝功能变化的原因

目的:探讨腹腔镜胆囊切除术后肝功能变化的原因。方法:将胆囊结石62例患者随机分为2组,A组32例,常规应用电刀切除胆囊,胆囊床普遍电凝处理;B组(对照组)30例,应用弯剪刀分离切除胆囊,钛夹钳闭止血。术后1、3、5、7d抽血测TBIL、ALT、AST、GGT、ALP含量。结果:A组术后第1天TBIL、ALT、AST明显升高,B组无升高,两组差异有显著性(P<0.01),A组术后第3天ALT、AST虽有下降,但仍高出正常值范围,差异仍有显著性(P<0.01),GGT、ALP两组均无明显升高。结论:电热损伤局部肝组织和肝外胆管的热电效应是术后肝功能变化的主要原因。     

腹腔镜胆囊切除术中肝中静脉分支损伤的危险性因素分析

目的探讨腹腔镜胆囊切除术中胆囊床出血的原因.方法对从2000年9月到2001年3月接受腹腔镜胆囊切除手术的617例中1例患者中,随机选取其中91例进行前瞻性分析,并对617例发生胆囊床出血的病例进行回顾性分析.结果多普勒超声检查均发现有1根肝中静脉的重要分支从胆囊床后面通过,该血管离胆囊床的最近距离点(C点)到胆囊的平均距离为(5.0±4.6)mm,其中15.4%(14例)肝中静脉是直接和胆囊床相贴,11.0%(10例)和胆囊床的距离在1mm以内,C点的内径为(3.2±1.1)mm;约有34.7%(31例)C点位于胆囊纵轴左侧,位于右侧的有39例(42.9%),正好落在胆囊纵轴上的有21例(23.1%).C点肝静脉的流速为(9.9±3.3)cm/s.结论肝中静脉最靠近胆囊点,较多会出现在胆囊纵轴的右侧.建议在术前,尤其是在腹腔镜胆囊切除术前进行常规的多普勒超声检查,以明确肝中静脉和胆囊床的关系,高度重视肝中静脉和胆囊床直接相贴的病例.     

腹腔镜胆囊切除术中肝中静脉分支损伤的危险因素分析

目的　探讨腹腔镜胆囊切除术中胆囊床出血的原因。方法　对 2 0 0 0年 9月～ 2 0 0 1年 3月接受腹腔镜胆囊切除手术的 617例患者中 ,发生胆囊床出血的病例进行回顾性分析 ,并随机选取其中 91例进行前瞻性研究。结果　多普勒超声检查均发现有 1根肝中静脉的重要分支从胆囊床后面通过 ,该血管离胆囊床的最近距离点 (C点 )到胆囊的平均距离为 ( 5 0± 4 6)mm ,其中 15 4 % ( 14例 )肝中静脉是直接和胆囊床相贴 ,11 0 % ( 10例 )和胆囊床的距离在 1mm以内 ,C点的内径为 ( 3 2± 1 1)mm ;约有 3 4 7% ( 3 1例 )C点位于胆囊纵轴左侧 ,位于右侧的有 3 9例 ( 4 2 9% ) ,正好落在胆囊纵轴上的有 2 1例 ( 2 3 1% )。C点肝静脉的流速为 ( 9 9± 3 3 )cm/s。结论　肝中静脉最靠近胆囊点 ,较多会出现在胆囊纵轴的右侧。建议在术前 ,尤其是在腹腔镜胆囊切除术前进行常规的多普勒超声检查 ,以明确肝中静脉和胆囊床的关系 ,高度重视肝中静脉和胆囊床直接相贴的病例。     

胆囊小细胞神经内分泌癌一例

患者女,69岁.因"间断右上腹痛1个月"就诊于我院.体格检查:未见明显阳性体征.实验室检查:血常规、肝功正常.肿瘤标志物AFP、CA-199、CEA均正常.肝胆胰CT平扫+三期增强:胆囊底可见类圆形软组织密度影,大小约2.4 cm ×2.5 cm,病变表面凹凸不平,局部与胆囊壁分界不清,部分突出胆囊轮廓之外,增强扫描动脉期呈不均匀强化,静脉期强化明显,延迟期强化减低,病灶与局部组织分界清楚(图1,2).肝实质内与局部组织分界清楚.肝实质内未见明显异常密度影,肝内胆管未见扩张.患者入院4d后行腹腔镜探查术,术中见胆囊底部游离缘肿物,内生型,胆囊周围无明显侵犯,镜下探查肝及腹腔重要脏器未见转移结节,肝十二指肠韧带周围未见肿大淋巴结.完整切除胆囊见肿物大小约2.0 cm ×1.5 cm,未侵及胆囊床,送快速病理学检查为:恶性肿瘤,倾向神经内分泌癌,切缘未见癌细胞.家属拒绝根治性手术,仅行胆囊切除术.病理学检查:胆囊神经内分泌癌(小细胞型,中-高度恶性)伴坏死.侵及浆膜下结缔组织,脉管内可见肿瘤浸润,神经未见肿瘤浸润(图3).免疫组化:CD56+、CK+、CgA+、Syn+(图4).     

肝中静脉属支与胆囊床关系的应用解剖研究

目的研究肝中静脉属支与胆囊床的关系。方法解剖观测137例成人肝脏标本中突入胆囊床的肝中静脉属支直径、长度、走行及距胆囊床较近肝中静脉的属支与胆囊壁的最短距离。结果突入胆囊床肝中静脉属支与胆囊壁的最短距离为(0.26±0.20)cm;突入胆囊床肝中静脉属支直径、长度分别为(0.31±0.04)cm、(2.85±1.55)cm。突入胆囊床的肝中静脉属支走行方向是由右前下向左后上。结论(1)突入胆囊床的肝中静脉属支破裂是引起胆囊切除时胆囊床大出血的重要原因;(2)在胆囊床由左前下向右后上方缝合肝组织是对突入胆囊床肝中静脉属支破裂出血的有效预防方法。     

腹腔镜胆囊切除术血清转氨酶的水平变化及原因

目的：比较腹腔镜下电刀与剪刀切除胆囊术后血清ＡＬＴ、ＡＳＴ水平变化,探讨氨酶升高的原因,方法１９９９年１１月收治的６９例胆囊结石患者随机分为两组。Ａ组３５例,电刀切除胆囊,胆囊床普遍电凝处理;Ｂ组（对照组）３４例,剪刀切除胆囊,钛夹钳闭止血,两组术中的气腹压均设定在２ｋＰａ,均于术后第１、５天测定血清ＡＬＴ、ＡＳＴ水平,结果Ａ组（电刀组）患者术后第１天ＡＬＴ、ＡＳＴ水平明显增高（Ｐ〈０．０１）,与     

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.     

Color Doppler Ultrasound Detection and Classification of the Tangential Hepatic Vein before Laparoscopic Cholecystectomy

Background: Unexpected fatal bleeding from the gallbladder bed during laparoscopic cholecystectomy is often associated with injury to the middle hepatic vein. This paper studies whether preoperative color Doppler ultrasound is effective in reducing the risk of injury. Also a venous classification is suggested. Methods: Between June 1999 and February 2004, 2,146 patients undergoing laparoscopic cholecystectomy by standard method received preoperative color Doppler ultrasound examinations. The closest distance between the hepatic vein and the gallbladder was studied. Also, cases of liver cirrhosis, number of conversions to open cholecystectomy, intraoperative blood loss, operative time, complications, and hospital stay were recorded (group D). At the end of the study, we retrospectively reviewed the same parameter of another 2,146 patients who received laparoscopic cholecystectomy without preoperative color Doppler ultrasound between the period of March 1995 and June 1999 (group ND). Results: In group D, 108 patients had cirrhosis. Four hundred and ninety-six patients (27 cases of cirrhosis) had a closest distance of 1 mm or less between the vein and the gallbladder. There were two conversions to open cholecystectomy, but none related to gallbladder bed bleeding. In group ND, there were five conversions, including four cases of gallbladder bed bleeding from the middle hepatic vein and one case of severe adhesion. The conversion rate was significantly higher. In group ND, the mean intraoperative blood loss in the cases of liver cirrhosis was significantly greater. Also, the operative time of patients with the closest vein and gallbladder distance of 1 mm or less in group D was significantly longer. Conclusions: Color Doppler ultrasound is an effective method for detecting the presence of potential bleeders. Although the operative time will be a bit longer, the operation can be done under meticulous care and complete preparation, so that the conversion rate and the risk of fatal hemorrhage can be reduced, especially in patients with liver cirrhosis.     

腹腔镜胆囊切除术后腹部及肩背部不适原因与处理

目的:总结腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)术后腹部及肩背部疼痛的原因及处理措施。方法:回顾分析31例LC术后腹部及肩背部疼痛患者的临床资料,总结其原因及相应处理措施。结果:31例患者中胃溃疡2例,胃癌1例,肝内胆管结石3例,胰腺假性囊肿1例,肠粘连2例,切口疝1例,肋弓下切口疼痛10例,胆囊窝积液8例(腹腔脓肿1例,胆囊床迷走胆管漏1例,胆囊床渗血1例,肝中静脉损伤1例,胆汁外溢4例),胆囊切除术后综合征3例。结论:术前完善检查、术中仔细操作减少不必要的副损伤、术后积极治疗,LC术后疼痛是完全可避免的。     

腹腔镜胆囊切除术中肝中静脉属支损伤的预防及处理

腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)中手术区域的出血是困扰外科医生的一个重要问题.除了胆囊动脉破裂之外,由胆囊床引发的出血也是LC术中常见的出血原因之一,而其中位于胆囊床后方肝中静脉属支的破裂所导致的胆囊床出血则更是术中非常棘手的问题,这不仅会使原本简单的手术复杂化,模糊手术区域的解剖结构,还往往可导致严重的手术并发症,是构成Lc术中转开腹的主要因素之一.本文就肝中静脉属支的局部解剖、损伤后的处理及损伤的预防进行综述.     

Hepatic vein injury during laparoscopic cholecystectomy: The unappreciated proximity of the middle hepatic vein to the gallbladder bed

Uncontrollable hemorrhage during laparoscopic cholecystectomy occurs in 0.1% to 1.9% of all cases, with 88% originating from the gallbladder bed. The anatomical proximity between major branches of the middle hepatic vein and the gallbladder bed, and hence the risk of intraoperative bleeding, is unclear. CT scans of 20 random patients were retrospectively reviewed to identify the closest distance between branches of the middle hepatic vein and the gallbladder bed. The vein diameter was also recorded. Risk factors for intraoperative bleeding during laparoscopic cholecystectomy were also retrospectively reviewed. Large branches (mean diameter=2.1 mm) of the middle hepatic vein are directly adjacent to the gallbladder bed in 10% of patients. An additional 10% of cases also possess branches within 1 mm of the gallbladder bed. Chronically scarred and contracted gallbladder disease may increase the risk of significant bleeding, requiring conversion. Twenty percent of all cases will display a large branch of the middle hepatic vein adherent or immediately adjacent to the gallbladder fossa. These patients are at increased risk for intraoperative bleeding. Furthermore, contracted gallbladders with evidence of chronic disease may be at increased risk for significant hemorrhage.     

Role of preoperative color doppler ultrasound scan in the evaluation of the risk of injury of major branches of the middle hepatic vein during laparoscopic cholecystectomy

During laparoscopic cholecystectomy, the separation of the gallbladder from the liver bed may sometimes cause severe hemorrhages. One reason for severe hemorrhages may be injury to the major branches of the middle hepatic vein (MHV), which may be too close or adherent to the gallbladder. In our institutional experience of 798 laparoscopic cholecystectomies, no major hemorrhage from the gallbladder bed has been encountered. The aim of this prospective study was to investigate the relationship between the major branches of the MHV and the gallbladder bed in our patients. We measured the distance of the closest branches of the MHV from the gallbladder bed by color Doppler ultrasound scan. The mean and the median distances of the closest branch of the MHV to the gallbladder was found to be 17.4 +/- 6.2 mm and 17.7 mm, respectively (range, 6-29.1 mm). In conclusion, the distance of the closest branch of the MHV to the gallbladder bed in our patient population seems to allow for a safe laparoscopic cholecystectomy.