困难性腹腔镜胆囊切除术围手术期处理体会

目的探讨困难类型腹腔镜胆囊切除围手术期的处理方法及并发症的预防。方法利用回顾性分析临床资料的方法,选择广东省中山大学附属东华医院1999年-2013年10月82例因急性胆囊炎、Mirizzi综合征、腹部手术史伴腹腔严重粘连、萎缩性胆囊炎、合并肝硬化等困难类型腹腔镜胆囊切除术的临床资料,总结经验和教训。结果除6例中转开腹(占7.31%)外,余均用腹腔镜成功完成手术;术后胆道损伤、胆瘘2例,再次手术后治愈;术后出血4例,保守治疗后痊愈;术后不明原因、不同程度胆漏者10例,经引流后自愈。结论对于困难类型腹腔镜胆囊切除术,虽然手术操作难度大,风险高,只要围手术期处理方法适当,仍可以在腹腔镜下完成手术。     

腹腔镜胆囊切除术并发症的发生机制与预防对策

腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)自从1987年3月由法国里昂一位妇科医生在进行腹腔镜附件手术时联合实施以来业已成为微创外科领域的经典示范手术。我国LC虽然在1991年初得以开展,20年多来远未像西方发达国家那样在3～5年内迅速普及发展起来,而是经历了较为漫长的探     

急性胆囊炎腹腔镜胆囊切除术53例临床分析

目的探讨急性胆囊炎行腹腔镜胆囊切除术（LC）的手术技巧。方法急性胆囊炎行LC 53例,中转开腹3例。回顾53例LC操作经验并进行总结分析。结果 50例LC手术成功,手术时间30～180 min,平均79 min,术中出血5～200 ml,平均住院6.5d（3～16 d）。结论急性胆囊炎首选LC。腹腔镜下顺行切除胆囊更加安全、快捷。     

Three-portal technique for laparoscopic cholecystectomy

We devised special maneuvers and techniques, which we refer to as “the three-portal technique,” for the performance of laparoscopic cholecystectomy. With this technique, the primary surgeon operates from the right side of the patient, beginning dissection at the posterior surface of the gallbladder and advancing until the neck of the gallbladder is sufficiently separated from the hepatic bed. The particular advantages of our technique are that the quadrate lobe of the liver does not obstruct the operative field, because of the direction of the dissecting forceps controlled by the operator’s right hand, and there is less contact between the various instruments. Sixteen patients with gallstones were successfully treated with this new technique, and no morbidity was attributable to the procedure.     

老年人腹腔镜胆囊切除术521例临床分析

目的探讨腹腔镜胆囊切除在治疗老年人胆囊良性疾病中的应用价值。方法回顾性分析５２１例老年患者胆囊切除术的结果。结果５２１例中，单纯慢性结石性胆囊炎４５９例，其中继发胆总管结石２例，急性胆囊炎２４例，胆囊息肉３８例。术中因炎性粘连、疑胆囊癌等改做开腹手术１８例（３．５％），发生严重并发症３例（０．６％），治愈４９９例（９５．８％），死亡１例。结论为老年人施行腹腔镜胆囊切除术，如医生经过充分的训练并了解可能发生的困难，仍是安全可行的手术方法。     

急性胆囊炎腹腔镜与开腹手术的对比分析

目的对比分析急性胆囊炎腹腔镜与开腹手术的临床疗效。方法回顾性分析2001年至2008年急性胆囊炎或慢性胆囊炎急性发作行胆囊切除术病例200例,其中行腹腔镜胆囊切除术（LC）67例,开腹胆囊切除术（OC）133例。结果LC组的术中出血量、手术时间、下床活动时间、肠道功能恢复时间、住院时间明显低于OC组（P〈0.05）;两组术后并发症发生率无明显差异（P〉0.05）。结论LC治疗急性胆囊炎的临床效果优于OC。     

An audit of ambulatory laparoscopic cholecystectomy in a Singapore institution: are we ready for day-case laparoscopic cholecystectomy?

Background. Day-Case laparoscopic cholecystectomy (LC) is practiced in many countries. However, this has yet to be widely accepted in Singapore. This study aims to determine the potential success rate of day-case LC in our institution. Patient and methods. We retrospectively assessed the proportion of our Ambulatory Surgery 23 hour (AS23) LC patients that met discharge criteria. Our proposed same-day discharge criteria include minimal pain, ability to tolerate feeds, ambulate independently and void spontaneously after 6–8 hours of monitoring. Results. From January 2005 to December 2006, of 405 patients listed for elective LC, 84% of patients were admitted to our AS23 ward. Patients with previous biliary sepsis or pancreatitis or who need laparoscopic common bile duct exploration (LCBDE) were included. The other 66 were admitted as inpatient. Forty-one of them were admitted due to conversion. A history of cholecystitis or cholangitis was a significant predictor of conversion to open surgery (OR=5.73 and 5.74 respectively, p<0.001). Of the 339 patients, 66% of them fulfilled all four criteria within eight hours of monitoring. Therefore, based on an intention-to-treat analysis, 51.2% fulfilled all four criteria and could potentially be discharged the same day. No predictor for failure was identified, including presence of co-morbidities, duration of operation, surgeon''s grade and additional procedures like LCBDE. Conclusion. Using our current inclusion criteria, we projected a success rate of at least 50% with the implementation of day-case LC. With the attendant advantages of cost savings and reduced resource utilization, it is therefore worthwhile to start it in Singapore.     

Transvaginal cholecystectomy vs conventional laparoscopic cholecystectomy for gallbladder disease:A meta-analysis

AIM:To compare the results of transvaginal cholecystectomy(TVC) and conventional laparoscopic cholecystectomy(CLC) for gallbladder disease.METHODS:We performed a literature search of Pub Med,EMBASE,Ovid,Web of Science,Cochrane Library,Google Scholar,Meta Register of Controlled Trials,Chinese Medical Journal database and Wanfang Data for trials comparing outcomes between TVC and CLC.Data were extracted by two authors.Mean difference (MD), standardized mean difference(SMD),odds ratios and risk rate with 95%CIs were calculated using fixed- or random-effects models.Statistical heterogeneity was evaluated with the χ2 test.The fixed-effects model was used in the absence of statistically significant heterogeneity.The randomeffects model was chosen when heterogeneity was found.RESULTS:There were 730 patients in nine controlled clinical trials.No significant difference was found regarding demographic characteristics(P 0.5),including anesthetic risk score,age,body mass index,and abdominal surgical history between the TVC and CLC groups.Both groups had similar mortality,morbidity,and return to work after surgery.Patients in the TVC group had a lower pain score on postoperative day 1(SMD:-0.957,95%CI:-1.488 to-0.426,P 0.001),needed less postoperative analgesic medication(SMD:-0.574,95%CI:-0.807 to-0.341,P 0.001) and stayed for a shorter time in hospital(MD:-1.004 d,95%CI:-1.779 to 0.228,P = 0.011),but had longer operative time(MD:17.307 min,95%CI:6.789 to 27.826,P = 0.001).TVC had no significant influence on postoperative sexual function and quality of life.Better cosmetic results and satisfaction were achieved in the TVC group.CONCLUSION:TVC is safe and effective for gallbladder disease.However,vaginal injury might occur,and further trials are needed to compare TVC with CLC.     

腹腔镜胆囊切除术后早期切口疼痛的相关因素分析

正近年来腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)以其安全、创伤小、痛苦轻、对腹腔脏器干扰小、住院时间短、术后恢复快[1]、高危患者能耐受等特点,逐渐成为治疗胆囊良性疾患的首选方法。但术后早期出现切口疼痛仍是患者最多见的主诉症状,严重影响患者术后康复及生活质量[2]。传统的单一镇痛模式已经不能满足患者的镇痛效果,需要更多     

术中胆道造影在腹腔镜胆囊切除术中的应用

目的探讨术中胆道造影（IOC）在腹腔镜胆囊切除术（LC）中的临床应用价值。方法回顾性分析2003年7月至2008年7月行LC病例442例,其中经ICO患者82例,占手术的18.4%。结果成功完成IOC 81例（97.5%）。发现胆总管结石13例（46.0%）,胆囊管结石4例（4.9%）,胆囊管汇入右肝管4例（4.8%）,胆总管远段狭窄3例（3.7%）,术中胆总管损伤1例（1.2%）。结论 LC中IOC对发现胆管结石的残留、及时发现胆管损伤、明确胆管解剖及变异均有帮助,值得在基层医院推广。     

日间手术腹腔镜胆囊切除1240例分析

目的探讨日间手术腹腔镜胆囊切除（LC/DS）的可行性和安全性,评价65岁以上老年患者LC/DS手术的效果。方法回顾性分析2009年11月至2010年12月我院1240例LC/DS临床资料,分析其并发症、延迟出院和再入院原因。比较65岁以下和老年患者LC/DS治疗效果。结果 1240例中1236例LC/DS手术成功,中转开腹4例（0.32%）。共发生6例（0.48%）并发症。延迟出院125例（10.1%）,其中49例（39.2%）因心理因素延迟出院,34例（27.2%）因手术后呕吐和腹痛延迟出院。再入院15例（1.2%）,8例因胆囊癌再入院。老年患者LC/DS无严重并发症,患者满意度与65岁以下组差异无统计学意义（P〉0.05）,延迟出院和再入院比例高于65岁以下组（P〈0.01）。结论日间手术腹腔镜胆囊切除安全可行,经选择的老年患者同样适合LC/DS医疗模式。心理因素、呕吐和腹痛是导致患者延迟出院的主要原因。     

复杂性胆囊腹腔镜切除术的体会

目的探讨复杂性胆囊腹腔镜胆囊切除术(LC)的方法。方法回顾分析2007年8月至2013年11月我科收治的81例复杂胆囊病患者的临床资料,其中急性胆囊炎66例,萎缩胆囊炎14例,Mirizzi综合征1例。所有腹腔镜手术在使用吸引器刮吸分离与超声刀切割相结合下完成。手术历时1.5~3 h不等。结果 79例LC手术成功完成,手术中1例肝总管损伤在腔镜下缝合修补,1例术中出血中转开腹手术,1例术前怀疑Mirizzi综合征,手术中确诊中转开腹手术。结论腹腔镜复杂性胆囊切除术安全可行。成功的关健是术前对病例进行认真讨论,术中使用吸引器与超声刀解剖Calot三角,胆囊切除采取顺行与逆行结合,全部切除与部分切除相结合,有效地避免术中大出血和胆管损伤,使腹腔镜下复杂性胆囊切除变得安全可靠。     

Pseudoaneurysm following laparoscopic cholecystectomy

BACKGROUND:Laparoscopic cholecystectomy(LC)is the operation of choice for removal of the gallbladder. Unrecognized bile duct injuries present with biliary peritonitis and systemic sepsis.Bile has been shown to cause damage to the vascular wall and therefore delay the healing of injured arteries leading to pseudoaneurysm formation.Failure to deal with bile leak and secondary infection may result in pseudoaneurysm formation. This study was to report the incidence and outcomes of pseudoaneurysm in patients with bile leak following LC referred to our hospital. METHODS:A retrospective analysis of our prospectively maintained liver database using pseudoaneurysm, bile leak and bile duct injury following laparoscopic cholecystectomy from January 2000 to December 2005 was performed. RESULTS:A total of 86 cases were referred with bile duct injury and bile leak following LC and of these,4 patients (4.5%)developed hepatic artery pseudoaneurysm(HAP) presenting with haemobilia in 3 and massive intra- abdominal bleed in 1.Selective visceral angiography confirmed pseudoaneurysm of the right hepatic artery in 2 cases,cystic artery stump in one and an intact but ectatic hepatic artery with surgical clips closely applied to the right hepatic artery at the origin of the cystic artery in the fourth case.Effective hemostasis was achieved in 3 patients with coil embolization and the fourth patient required emergency laparotomy for severe bleeding and hemodynamic instability due to a ruptured right hepatic artery.Of the 3 patients treated with coil embolization, 2 developed late strictures of the common hepatic duct. . (CHD)requiring hepatico-jejunostomy and one developed a stricture of left hepatic duct.All the 4 patients are alive at a median follow up of 17 months(range 1 to 65)with normal liver function tests. CONCLUSIONS:HAP is a rare and potentially life- threatening complication of LC.Biloma and subsequent infection are reported to be associated with pseudoaneurysm formation.Late duct stricture is common either due to unrecognized injury at LC or secondary to ischemia after embolization.     

选择性术中胆道造影在腹腔镜胆囊切除术中的应用价值

目的探讨选择性术中胆道造影（PTC）在腹腔镜胆囊切除术（LC）中的应用价值。方法回顾分析35例行LC的患者在术中经胆囊管插管进行胆管造影的结果。结果 35例LC术中胆管造影均成功,术中发现胆总管结石4例,行腹腔镜胆道探查、T型管引流术。结论 LC术中胆管造影操作方便可行,显影清晰,成功率高,能发现术前未能发现的胆总管结石有效的降低胆管残石率,通过造影还可以排除胆道结石,避免阴性探查,减少患者痛苦,在复杂胆囊切除术中可帮助辨别解剖关系、发现解剖变异,避免术中胆管损伤,提高了LC手术的质量和安全性。     

择期和急诊腹腔镜胆囊切除术治疗急性胆囊炎患者临床效果比较研究

目的 比较择期腹腔镜胆囊切除术（SLC）与急诊LC治疗急性胆囊炎患者的临床应用效果。方法 2014年1月～2016年6月我院诊治的92例急性胆囊炎患者,其中应用SLC治疗52例,应用急诊LC治疗40例。在行SLC时,先行在B超实时引导下经皮经肝胆囊穿刺引流术,抽出胆汁,同时予以抗感染治疗。在炎症控制后3月,再入院行LC,在行急诊LC时,于发病72 h内行急诊LC术,手术中依照常规方法留置腹腔引流管,手术结束后进行抗感染治疗。结果 两组均成功顺利完成手术。SLC治疗患者手术时间、肛门排气时间和术后住院时间分别为（60.2±7.0） min、（24.1±3.3） h和（5.6±1.3） d,中转开腹和胆道损伤发生例数分别为3例（5.8%）和0例（0.0%）,而急诊LC治疗组则分别为（58.7±8.1） min（P=0.784）、（26.2±5.8） h(P=0.047)和（8.1±1.9） d(P=0.029),中转开腹和胆道损伤发生例数分别为8例（20.0%, P=0.018)和7例（17.5%, P=0.039); SLC组术后发生出血、肺部感染、切口感染和胆漏等并发症发生率为5.8%,显著低于对照组的25.0%（P<0.05）。结论 SLC术治疗急性胆囊炎患者临床效果好,更安全,应尽量减少行急诊LC术治疗急性胆囊炎患者。     

Avoidance of biliary injury during laparoscopic cholecystectomy

Biliary injury during laparoscopic cholecystectomy is still a serious problem. Injury occurs as a result of technical errors or misidentification of ducts. Inexperience, inflammation, and aberrant anatomy are key risk factors. The most serious technical problem is cautery‐induced injury. This problem may be avoided by use of cautery under very low power settings in the triangle of Calot. Misidentification injuries occur when the surgeon mistakes the common bile duct or an aberrant right hepatic duct for the cystic duct. This error usually occurs when the surgeon uses the “infundibular” technique to identify the cystic duct. This technique, which depends on seeing the cystic duct flare as it becomes the infundibulum, is especially prone to be misleading in the face of acute inflammation. This technique is unreliable and should not be used alone for anatomic identification of the ducts. It is preferable to use the critical view technique or to perform a cholangiogram.     

Port site recurrences after laparoscopic cholecystectomy

Port site metastasis is a well‐documented event after laparoscopic procedures in cancer patients. We summarize current epidemiological knowledge about the risk of this complication after laparoscopic/conventional cholecystectomy in patients with unexpected gallbladder cancer as well as other intraabdominal malignancies. We found 174 cases of port site metastasis after laparoscopic cholecystectomy and 12 recurrences in the surgical scar after converted or open cholecystectomy. A review of all case reports and its comparison with four international surveys show a 14% incidence of port site metastases 7 months after laparoscopic cholecystectomy for cancer. Similar numbers are available for open cholecystectomy. Our data suggest that abdominal wall metastases of gallbladder cancer are not a specific complication of laparoscopy. The long‐term prognosis of patients with unknown gallbladder cancer however seems to be worsened by laparoscopy. The registry of the German Society of Surgery, which prospectively compares follow‐up and prognosis of all cases of cholecystectomy, laparoscopic as well as open, in patients with incidental gallbladder cancer will definitively clarify whether laparoscopy affects the prognosis of patients with unsuspected gallbladder cancer.     

Telerobotic-assisted laparoscopic cholecystectomy: our experience on 29 patients

Background/Purpose

The role of computer-assisted surgery (CAS) is still debated and not clearly defined.

Methods

The authors report their initial experience with CAS, comparing 29 patients submitted to cholecystectomy, using a Zeus remote-controlled robot and an Aesop remote voice-activated endoscope robot, with 29 patients submitted to standard laparoscopic cholecystectomy (LC). The surgical field and the arms of the robot were under the direct and real-time control of the surgeon, who stayed at the workstation and maneuvered the Zeus, using joysticks. The workstation was in the same room as the patient.

Results

Twenty-nine patients underwent telerobotic-assisted cholecystectomy (TLAC); 1 procedure was converted to standard LC and 1 to open cholecystectomy. The conversions were due to choledocholithiasis and cholecystitis. During TLAC, the mean operating time and transition time (from the induction of anesthesia to incision of the skin) were, respectively, 75?min (range, 60–170?min) and 45?min (range, 25–60?min). We did not observe any complications related to TLAC. The limitations of TLAC were the lack of tactile feedback, the increase in surgical time, and the expensive cost of the procedure to reach the same result as that of LC.

Conclusions

After this initial experience, we believe that TLAC could be considered only for training in CAS, but that it is without advantages in terms of its higher cost compared with LC.