免钛夹腹腔镜胆囊切除术的方法及效果分析

目的对免钛夹腹腔镜胆囊切除术的手术方法以及治疗效果进行探究。方法对2009年1月至2012年8月收治的226例接受免钛夹腹腔镜胆囊切除术治疗的患者的临床资料进行回顾性分析，观察患者临床治疗的效果和并发症的发生情况。结果226例患者接受手术治疗之后，均结扎成功没有出现中转开腹现象和并发症。结论利用免钛夹腹腔镜胆囊切除术为患者进行胆囊切除不仅经济且安全、可靠，值得在临床中应用推广。     

腹腔镜下胆囊切除术打结法（附996例报告）

目的探讨在腹腔镜胆囊切除术（LC）中应用普通丝线，不增加任何特殊器械，在腹腔内结扎胆囊管和胆囊动脉的安全性和可靠性。方法分析2003年8月～2007年10月，我院为996例患者行LC打结法的临床资料。结果995例治愈，中转开腹4例，占0．41％，死亡1例，死于麻醉意外。结论LC术中普通丝线取代钛夹结扎胆囊管和胆囊动脉，安全、可靠、经济。避免体内金属异物残留，而且能避免使用钛夹所致的并发症。     

自制套扎线无钛夹腹腔镜胆囊切除术的临床研究

目的 探讨自制套扎线无钛夹腹腔镜胆囊切除术的临床疗效.方法 选取2003年3月～2008年1月间施行腹腔镜胆囊切除术(LC)患者86例,随机分为使用自制套扎线无钛夹LC组(观察组)43例和传统钛夹LC组(对照组)43例;比较两组手术时间、术中出血量、右上腹疼痛不适、胆漏、其他并发症,住院时间的差异.结果 两组均结扎成功并顺利出院,观察组与对照组比较手术时间延长、术中出血量增加(P<0.05),住院时间、术后恶心呕吐胃肠反应、发热等其他并发症差异无显著性(P>0.05);右上腹疼痛不适减少(P<0.05),未发生胆漏.结论 自制套扎线无钛夹腹腔镜胆囊切除术处理胆囊管及胆管动脉安全、可靠,并能避免使用钛夹所致的并发症.值得推广和应用.     

超声刀在腹腔镜胆囊切除术中的应用(附485例报告)

[目的]总结超声刀在腹腔镜胆囊切除术中的应用方法、技巧、注意事项、及实现去钛夹化优越性的体会.[方法]基本同常规LC方法,丝线结扎胆囊管后切断之,胆囊动脉及胆囊床组织用超声刀分离、剥离、凝固、切割止血.[结果]本组485例均痊愈出院,其中中转开腹11例.体内保留钛夹79例,胆囊破裂45例,放置腹腔引流管54例.[结论]在LC手术中超声刀的应用,具有以下优越性:①止血效果好;②切割精确;③安全性高;④手术时间短;⑤基本实现去钛夹化优点.但是,若使用不当,仍能引起严重的副损伤及并发症.     

无钛夹腹腔镜胆囊切除术625例经验

目的探讨无钛夹法处理胆囊管及胆管动脉在腹腔镜胆囊切除术中的应用。方法回顾性分析腹腔镜无钛夹法胆囊切除625例，术中应用超声刀或单极电刀封闭切断胆囊动脉，丝线结扎、套扎器结扎或可吸收夹结扎疸囊管。结果术后无1例病人出现腹腔感染、胆漏和出血等并发症。术后随访1-12个月。未见有腹痛、肩背部疼痛、黄疸及发热等症状。结论腹腔镜胆囊切除术中无钛夹法处理胆囊管及胆管动脉安全、可靠。能避免使用钛夹所致的并发症。     

腔内“线扎法”在腹腔镜胆囊切除术中处理胆囊管及胆囊动脉的临床探索

腹腔镜胆囊切除术(Laparoscopic Cholecystectomy简称，LC)中运用腔内“线扎法”处理胆囊管、胆囊动脉，使其与剖腹胆囊手术的“百年处理方式”一致，让LC手术病人体内无夹化，有效防范了金属夹结扎方式上的蔽端及其放置不当时所致的并发症发生。现报导如下：     

三孔缝扎法腹腔镜胆囊切除术的探讨

目的：探讨三孔缝扎法腹腔镜胆囊切除术（LC）的手术方法和适应证。方法：全麻下采用三孔缝扎法行逆行法LC，脐下缘皮肤戳第一孔（10mm）置入腹腔镜，剑突下2－5cm戳孔（10mm)为主操作孔，右锁骨中线肋缘下2cm偏外2－5cm处戳孔（5mm)为辅助操作孔，借助腹腔镜弯钳和腹腔镜持针器1－0可吸收缝线腹腔内打外科结结扎和3－0可吸收缝针线缝扎双重处理胆囊管，打外科结结扎和／或缝扎单重或双重处理胆囊动脉前后分支，胆囊从剑突下孔或脐部孔取出。结果：67例中成功施行三孔缝扎法LC53例（79％），三孔结扎法LC4例，三孔钛夹法LC9例，四孔缝扎法LC1例。无手术并发症。结论：选择合适病人施行三孔缝扎法LC较安全、可行，此方法避免了钛夹和丝线的残留，减少了一个腹壁戳孔，病人容易接受。     

腹腔镜下对增粗胆囊管妥善结扎方法的探讨

目的：研究和探讨腹腔镜下采用中号钛夹对增粗胆囊管的妥善结扎方法。方法：将胆囊管增粗（直径≥0.8cm）者131例分为A组82例，采用中号钛夹多次夹闭切开法；B组49例，采用腹腔内丝线结扎加中号钛夹夹闭法。结果：A组术后发生胆囊管胆汁漏2例（2／82，2．44％），平均每例闭合切断胆囊管所用钛夹6枚（4枚－8枚）。B组术后无胆囊管胆汁漏发生者，平均每例闭合切断胆囊管所用钛夹3枚（2－4枚）。结论：B组方法实为一种安全经济的腹腔镜下增粗胆囊管的结扎方法，值得采用。     

超声刀生物夹在腹腔镜胆囊切除术中的应用

目的探讨腹腔镜胆囊切除术(LC)中应用超声刀及生物夹的安全性和可靠性。方法对203例患者行LC术中采用超声刀生物夹的临床资料进行回顾性分析。结果 203例患者胆囊管均一次结扎、凝断成功,无中转开腹病例。所有患者术后无胆囊管残端胆漏及出血等并发症,术后无需止痛处理,住院时间3～4d,均痊愈出院。结论 LC术中生物夹结扎胆囊管,继以超声刀凝断胆囊管和胆囊动脉,安全、可靠,能避免体内金属异物残留。     

腹腔镜胆囊切除术中丝线结扎胆囊颈管和胆囊动脉应用体会

目的探讨腹腔镜胆囊切除术中丝线结扎胆囊颈管和胆囊动脉技术,观察其临床效果。方法对我院2006年11月至2009年1月112例腹腔镜胆囊切除术中应用丝线结扎胆囊颈管和胆囊动脉的临床资料进行回顾性分析。结果112例全部顺利完成,无中转开腹,无术后大出血、胆瘘等并发症发生,术后肠道功能恢复时间、术后住院时间等恢复指标与使用钛夹病例类似。结论腹腔镜胆囊切除术应用丝线结扎胆囊颈管和胆囊动脉,可以不使用钛夹,手术安全可靠,具有临床应用价值。     

Adverse consequences of cystic duct closure by clips

Summary

Laparoscopic cholecystectomy (LC) is now established as the standard alternative to open cholecystectomy. It is safe with a reported complication rate ranging from 0.5 to 5%. The majority of surgeons performing LC employ metal and, less frequently, absorbable polydioxanone clips to secure the medial end of the cystic duct. Only a small minority ligate the cystic duct in continuity or by the use of an endoloop. Bile duct leakage from the cystic duct Is the most common technical complication after LC with a reported range of 0–7% and a median prevalence of 2%. Instances of metal clip migration and internalization into the common duct, although rare, have also been reported. Both these complications can be prevented by the routine practice of ligature of the medial end of the cystic duct by an external slip knot of the Roeder type using dry catgut.     

Endoscopic clipping of perforation following pneumatic dilation of esophagojejunal anastomotic strictures

Two patients with small perforations occurring after endoscopic balloon dilation of esophagojejunal anastomotic strictures were treated conservatively using metal clips. Closure of the perforation was achieved in both cases, using one and two clips in a single session. There was no procedure-related morbidity and no patient developed complications. Patients were discharged from hospital on days 4 and 5, respectively. In patients with esophagojejunal anastomotic strictures, endoscopic treatment of postdilation perforation by metal clips is safe and effective.     

内镜下放置金属夹后长期存留在消化道对人体的影响*

目的探讨内镜下放置金属夹后长期存留在消化道对人体的影响。方法收集2016年1月-2018年3月该院内镜中心在内镜诊疗中发现消化道有金属夹存留1个月以上的46例患者资料。结果存留时间1个月~5年,平均存留(7.0±0.4)个月。上消化道存留25例,大肠存留21例,共46例,同期使用金属夹的患者共1 498例,占3.1%。上消化道金属夹氧化(锈蚀)8例,占32.0%,大肠存留的金属夹有1枚部分氧化,占4.8%;局部有炎症改变的25例;存留1枚的40例,存留2枚的5例,存留3枚的1例;1例直肠息肉钳除后11个月复查结肠镜发现原部位存留1枚钛夹,并出现1枚新的息肉,病理结果示增生性息肉,局部有明显慢性肉芽肿性炎症改变的13例,占28.3%。上消化道金属夹存留者17例有腹痛症状,占37.0%,大肠金属夹存留患者腹痛1例,占2.2%,腹泻3例,占6.5%。结论金属夹长期存留在消化道有可能导致局部炎症改变及炎性息肉形成,也可引起腹痛、腹泻症状,酸性环境对金属夹有明显氧化(锈蚀)作用,可能诱发毒性反应,应引起内镜及临床医师高度重视。     

Salvage treatment of laparoscopic cholecystectomy‐associated bile duct stenosis combining laparoscopic and endoscopic procedures: A case report

The incidence of laparoscopic cholecystectomy (LC)‐associated bile duct injury has reached a steady state despite learning curve effect. Herein we report the case of a 74‐year‐old Japanese man who suffered from bile duct stenosis and stones after LC. The stenosis was due to stricture caused by surgical clips used inappropriately during LC. We planned a salvage treatment combining laparoscopic and endoscopic approaches. At laparoscopic observation, the clips had already invaded the right side of the bile duct; minimal absorbable suture was performed after all the clips were removed. The bile duct stenosis was then endoscopically dilated and the biliary stones were successfully removed. For the recurrent biliary stenosis after discharge, endoscopic balloon dilation was performed and multiple plastic stent tubes were placed. The stent tubes were removed 4 months later, and the patient has had no symptoms for 1 year. A combined laparoscopic and endoscopic approach was useful for the salvage treatment of LC‐associated bile duct stenosis.     

It is time for a better clip applier – 3 mm,percutaneous, non-crushing and locking

Introduction: Since the advent of laparoscopy there have been attempts to minimize abdominal wall incisions. For this purpose smaller instruments have been produced. Our aim was to develop the first 3?mm percutaneous clip applier and to make it better than the standard clips of today.

Material and methods: The ClipTip clip is made of Nitinol and has a crocodile shaped jaws, which when apposed effectively seal vessels. The shaft operates as a retractable needle permitting percutaneous insertion. Closing, reopening and reclosing is possible. The physical properties of the device were compared to three commercially available clip appliers. Surgeries were performed on porcine animals by experienced surgeons.

Results: In comparison to available clips, the superiority of the ClipTip is a combination of wide effective length alongside the ability to withstand strong forces. In live animal studies the Cliptip was inserted into the peritoneal cavity without any injuries. Vessels were ligated successfully and no clip dislodgement or leakage occurred.

Conclusions: We developed the next generation clip applier with better properties. Advantages include its length, the needleoscopic caliber, non-crushing effect, locking mechanism and wide aperture. The device has performed safely and effectively in pre-clinical tests. Further studies are planned in humans.     

组织胶联合金属夹治疗孤立性胃底静脉曲张(IGV1型)21例疗效分析

目的探讨胃镜下组织胶联合金属夹治疗孤立性胃底静脉曲张(IGV1型)的临床疗效。方法回顾分析2015年1月-2016年12月该院胃镜下组织胶联合金属夹治疗肝硬化IGV1型患者21例的临床资料,并结合相关文献进行分析。结果 21患者治疗均顺利完成,第1周、第1个月、第3个月、第6个月复查胃镜,胃底静脉曲张明显减少,无明显大出血、栓塞等严重并发症。结论组织胶联合金属夹治疗肝硬化IGV1型具有临床意义,可为临床处理该类疾病提供参考。     

Emergency liver resection for combined biliary and vascular injury following laparoscopic cholecystectomy: case report and review of the literature

A 75-year-old woman suffering from symptomatic cholelithiasis was admitted to our hospital for elective laparoscopic cholecystectomy (LC). Intraoperatively, because of severe inflammation and dense adhesions in the region of the Calot triangle and bleeding arising from the porta hepatis which obscured the operating field, the method was converted to a conventional open approach. Copious hemostasis was achieved using sutures, clips and diathermy, and no bile duct or vascular injuries were recognized intraoperatively. Because of severe right upper quadrant abdominal pain and significant deterioration of the liver function tests (LFTs) on the first postoperative day, the patient underwent a Doppler ultrasound scan which showed absence of blood flow at the level of porta hepatis. Urgent relaparotomy revealed an ischemic liver on the right, a transected common bile duct at the level of its confluence, a divided and ligated right hepatic artery and thrombosed portal vein down to its confluence. Thrombectomy and reconstruction of the portal vein were performed to salvage the left hemiliver, and after restoration of blood flow to the left hemiliver, a right hemihepatectomy and a Roux-en-Y hepaticojejunostomy on the left were performed. Liver resection serves an important role in the case of parenchymal necrosis due to combined biliary, hepatic artery and portal vein injury following laparoscopic cholecystectomy and moreover, the operation can be safely performed in the acute setting.     

经内镜钛夹治疗急性消化道出血48例分析

目的验证金属钛夹在急性消化道出血的临床应用价值。方法2001年6月-2004年9月随机急性消化道出血行急诊内镜检查发现出血灶和内镜下治疗后即时大出血患者共计48例。选用奥林巴斯（Olympus）HX-5LR-1型和HX-5QR-1型钛夹置放操作器以及HX-600—135型金属钛夹，对准出血部位两端，钳夹出血血管及附近组织，并用生理盐水局部喷洒冲洗，确认完全止血。结果48例共使用金属钛夹121枚。总有效率100％。结论金属钛夹治疗各种消化道出血是一种安全有效、无明显并发症、止血效果显著的治疗措施，值得临床推广应用。     

Metal-free laparoscopic distal pancreatectomy using transpancreatic mattress suture with polyglycolic acid sheet and fibrin glue: A case report

Laparoscopic distal pancreatectomy (LDP) is the standard surgery for malignant and premalignant tumors of the pancreatic body and tail. A stapler is commonly used to close the pancreatic stump due to its simplicity; however, the use of a stapler is associated with the risk of metal allergy and postoperative pancreatic fistula, especially in thick pancreases. Here, we present a case of LDP without metal instruments, including staplers and clips, in a 54-year-old woman with a metal allergy and a thick pancreas. The pancreatic stump was closed using the transpancreatic mattress suture method with a polyglycolic acid sheet (PGA) and fibrin glue. The postoperative course was uneventful. Metal-free LDP is useful and can be adopted regardless of the patient's background, such as a metal allergy or pancreatic thickness.     

三孔打结法腹腔镜胆囊切除术326例

目的：采用三孔打结法行腹腔镜胆囊切除术（LC），进一步减少手术创伤。方法：326例患者在全麻下采用三孔打结法行LC，脐部皮肤皱褶处截第一孔（10mm)置入腹腔镜，剑突下稍偏右截孔（5mm）为主操作孔，右锁骨中线肋缘下2cm处截孔（5mm）为辅助操作孔，借助自制的打结器，应用丝线结扎处理胆囊管及胆囊动脉，胆囊从脐部孔取出。结果：采用此方法行LC成功率达100％，手术时间无明显延长，术后恢复快。结论：三孔打结法LC是一种安全、可行的方法，此方法进一步减少了手术的创伤，有利于术后恢复。