免气腹腹腔镜胆囊切除术在老年患者中的应用体会

目的：总结免气腹腹腔镜胆囊切除术（gasless laparoscopic cholecystectomy, GLC）在老年患者中的应用价值及临床体会。方法：回顾分析2013年1月至2013年7月为12例老年慢性胆囊炎、胆囊结石或胆囊息肉患者行GLC的临床资料,记录手术时间、麻醉时间、术后恢复情况、并发症、住院时间等指标。结果：手术均获成功,无一例中转开腹。手术时间平均（46．67±7．49）min,麻醉时间平均（72．08±8．65）min,术后首次肛门排气时间平均（26．55±16．01）h,术后首次肛门排便时间平均（51．64±16．49）h。均无胆漏、心肺功能障碍加重、颈肩痛及术后恶心呕吐。平均住院（5．92±1．24）d,患者均治愈出院。术后随访1～6个月,均无胆管狭窄、残余结石等并发症发生。结论：GLC避免了CO2气腹对呼吸系统、循环系统的影响,提高了手术安全性,对于合并心肺功能障碍的老年患者是较理想的选择。     

肺功能障碍患者非气腹腹腔镜胆囊切除术

目的探讨肺功能障碍者行非气腹腹腔镜胆囊切除手术的安全性。方法9例（肺功能损害轻度3例，中度6例）均在硬膜外麻醉下手术。其中非感染期阻塞性通气功能障碍或（和）混合性通气功能障碍7例（1例有哮喘史），单肺切除1例，一侧肺部分切除1例。直视下从脐下切口进腹，从切口处置入腹壁提升器的柄，角度张开的大小根据患者个体实际情况调整，以提起后达到最佳的暴露空间为准。手术操作与气腹腹腔镜相同。结果9例均安全地在硬膜外麻醉下施行非气腹腹腔镜胆囊切除手术，手术时间30—103mm，平均51min，无中转开腹，未出现手术并发症。结论在密切的麻醉监护下，硬膜外麻醉结合非气腹腹腔镜对肺功能障碍患者行胆囊切除手术仍是安全可靠的。     

空气与二氧化碳气腹腹腔镜胆囊切除术的比较

目的 比较空气与CO2气腹腹腔镜胆囊切除术（1aparoscopic cholecystectomy,LC）的临床效果,探讨空气膨腹介质下LC的临床应用价值。方法2013年7～10月109例胆囊良性疾病按本科手术日分为2组,分别施行空气气腹或c0,气腹LC,前者除使用空气气腹外,余均使用常规的腹腔镜手术设备和操作器械,比较2组手术并发症、疼痛反应、术后住院时间、总住院费用等。结果 2组均顺利完成LC,无中转开腹、严重并发症发生。空气组无一例中转CO2气腹手术,与CO2组比较,空气组术后肩痛发生率低（X^2=4.097,P=0.043）、恶心呕吐发生率低（X^2=4.584,P=0.032）、视觉模拟评分低（t=-3.568,P=0.000）、术后排气时间短（Z=-4.287,P=0.000）、术后住院时间短（t=2.312,P=0.023）、住院费用低（t=-3.854,P=0.000）。结论 空气气腹LC安全可行,简易价廉,减少CO2排放,减轻CO2气腹术后并发症。     

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。     

腹腔镜胆囊切除术CO2气腹对脑脊液压的影响

在腹腔镜胆囊切除术５００例中，选择３０例患者应用航天医学工程研究所ＬＯＹ－Ⅲ型颅内压监测仪于术中脑脊液压作了连续监测，观察插管前，插管后，ＯＣ２气腹过程及手术后ＣＳＦＰ的变化情况。发现气腹过程中ＣＳＦＰ与气腹压呈趋势一致的升降，提示气腹对ＣＳＦＰ产生显著影响。     

腹腔镜胆囊切除术气腹对未规范治疗的高血压患者血压的影响

目的:探讨腹腔镜胆囊切除术(LC)气腹对未规范治疗的高血压患者血压的影响.方法:将行LC手术的患者分为3组,每组20例,A组(20例)有高血压病史,术前未行规范治疗;B组(20例)有高血压病史术前行规范治疗;C组(20例)无高血压病史.检测3组患者气腹前(T1),气腹后5 min(T2),15 min(T3),30 min(T4),气腹解除后10 min (T5)平均动脉压(MAP).结果:3组间T1期比较差异无统计学意义(P＞0.05);A组T2,T3,T4,T5时点MPA均高于B组和C组(P＜0.01),B,C两组间各时点比较无统计学差异(P＞0.05).结论:气腹对未规范治疗高血压患者的血压有明显影响.     

腹腔镜胆囊切除术在老年患者中的应用

胆囊良性外科疾病（胆囊结石,胆囊息肉,功能障碍的非结石性胆囊炎）是老年人常见多发病,随着年龄的增大,其发病率明显升高。腹腔镜胆囊切除术（LC）在老年患者也得到了广泛应用,并较传统胆囊切除术（OC）具有明显的微创特征。     

气腹与非气腹腹腔镜胆囊切除的随机对照研究

目的探讨腹壁悬吊式非气腹装置在腹腔镜手术中的应用价值。方法采用随机对照方法比较非气腹（n=37）与CO2气腹（n=38）腹腔镜胆囊切除术的手术时间、术中出血量、术后即时动脉血气分析、术后住院时间、术后第1天血ACTH变化及术后并发症情况。结果2组均顺利完成手术,气腹组手术时间（34.2±7.7）min显著短于非气腹组（46.7±16.8）min（t=-4.160,P=0.000）,气腹组术中出血量（10.4±2.0）ml显著少于非气腹组（14.8±7.2）ml（t=-3.627,P=0.000）。术后即时动脉血气分析、术后住院时间[气腹组为（3.7±0.7）d,非气腹组为（3.9±1.2）d,t=0.884,P=0.379）]和术后第1天ACTH（气腹组中位数为5.66pmol/L,非气腹组中位数为5.48pmol/L,Z=0.748,P=0.436）2组比较差异无统计学意义。术后2组均无严重并发症,非气腹组37例中有20例出现了右季肋部皮下气肿,气腹组无此并发症出现。结论腹壁悬吊式非气腹装置安全简单,患者术后恢复好,并可避免气腹手术的相关并发症,拓宽了腹腔镜手术的应用范围,具有在临床推广应用的价值。     

不同CO2气腹压力对腹腔镜胆囊切除术后肩痛的影响

目的研究不同CO2气腹压力对腹腔镜胆囊切除术(LC术)后肩部疼痛的影响。方法将100例行LC术的患者随机分为两组,每组50例,分别设定气腹压力为1.2kPa(10mmHg)和2kPa(15mmHg)下行LC术。对比两组术后肩部疼痛发生率及程度。结果在1.2kPa下手术组,患者的术后肩部疼痛程度明显低于2kPa手术组,差异有统计学意义(χ2=22.698,P<0.05)。结论LC术后肩部疼痛的主要原因可能与人工气腹张力对膈肌牵拉刺激有关。在10mmHg低压气腹下行LC术,可显著降低LC术后肩部疼痛的发生率及程度。     

腹腔镜胆囊切除术在老年患者中的应用

目的 探讨腹腔镜胆囊切除术在老年患者中的应用.方法 回顾性分析60例老年急性胆囊炎患者应用腹腔镜治疗的临床资料.结果 本组60例均在腹腔镜下完整切除病变胆囊,住院时间5～19 d,无手术并发症.60例均痊愈出院,无死亡病例.结论 术前仔细评估患者具体手术适应证,规范操作,及时处理术中、术后各项并发症,是老年急性胆囊炎腹...     

Laparoscopic Cholecystectomy in Elderly Patients

Background and Objective:

In this study, we investigated whether laparoscopic cholecystectomy, a minimally invasive procedure, is advantageous in elderly patients.

Methods:

Data from 595 patients who underwent laparoscopic cholecystectomy between January 2003 and December 2007 were prospectively collected in a database. The patients were separated into 2 groups; patients >70 years of age (group A), and patients <70 years of age (group B). Group A was further divided into 3 subgroups, ages 70 to 74, 75 to 79, and 80 and above. Comparison between the groups was made with Mann-Whitney U and chi-square tests where appropriate.

Results:

ASA scores increased in conjunction with increased age (P<0.001). Of patients with an operative time longer than one hour, 26 patients aged 70 or older, and 152 patients aged 69 or younger had no difference with respect to PaCO₂ and pH measurements (P>0.05). In patients aged 80 or older, the rates of acute cholecystitis, conversion to open surgery, and postoperative complications were significantly higher than in other groups (P>0.05).

Conclusion:

We believe that in elderly patients, laparoscopic surgery can be applied safely without further increasing the surgical risks. The complications can be minimized by carefully selecting the patients aged 80 or older and by experienced teams with high technical capabilities operating on such patients.     

浆膜下CO_2气垫法在腹腔镜胆囊切除术中的应用

目的探讨浆膜下CO2气垫法腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)的方法、适应证与应用价值。方法 2009年1月～10月,对47例LC于施行胆囊切除前,分别在胆囊三角区和胆囊床进行穿刺,浆膜下层注入CO2,使浆膜下层形成气垫,组织更加疏松,层次感放大,血管及胆管显露更清晰,然后按常规方法切除胆囊。结果 41例成功完成浆膜下CO2气垫法LC,术中易于清晰解剖与处理Calot三角区的血管及胆管结构,胆囊床组织疏松,易于掌握分离层面,分离显得简单、快捷,术中出血10 ml,手术时间11～29 min,平均17 min。另6例因胆囊床及胆囊三角慢性炎症"冰冻"样改变、急性炎症水肿严重、胆囊萎缩等原因无法采用本方法,而改行常规LC。所有患者手术顺利,无中转开腹,无术中大出血、胆管损伤等并发症。47例随访2～10个月,平均7个月,无再发胆绞痛、发热、黄疸,复查B超无胆管扩张、胆管狭窄、胆道结石。结论在LC术中,浆膜下CO2气垫法对辨认胆管及血管、增加胆囊床浆膜下间隙有帮助,放大层次感,利于清晰解剖与处理Calot三角区的血管及胆管结构,对帮助掌握胆囊床分离的层面等具有明显的作用,有一定的临床应用推广价值。     

老年患者行低气腹压腹腔镜胆囊切除术的可行性

目的探讨老年患者在低气腹压下行腹腔镜胆囊切除术的可行性。方法 2009年1月～2011年8月,对100例老年患者行腹腔镜胆囊切除术,其中51例低气腹压（6～8 mm Hg）,49例常规气腹压（15 mm Hg）。比较2组手术时间、术中出血量、住院时间、术后并发症发生率等。结果 100例老年患者均顺利完成腹腔镜胆囊切除,无中转开腹。低压组手术时间（46.6±20.7）min与常规压组（42.7±22.3）min差异无显著性（t=0.907,P=0.367）;低压组术中出血量（52.5±25.3）ml与常规压组（42.1±30.3）ml差异无显著性（t=1.867,P=0.065）;低压组住院时间（4.9±2.6）d与常规压组（4.5±2.3）d差异无显著性（t=0.765,P=0.446）;低压组术后并发症9例,与常规压组8例差异无显著性（χ2=0.031,P=0.860）。结论选择低压气腹对非高危病人是可行的,对高危病人是必要的,进行低气腹压LC安全可行。     

悬吊式免气腹腹腔镜辅助下胆囊切除术患者的护理

目的 探讨悬吊式免气腹腹腔镜辅助下胆囊切除术患者的有效护理方法,促进患者康复.方法 对23例患者给予心理护理、术前准备、术后常规护理、饮食护理、腹壁穿孔的观察与护理及并发症的预防与护理等措施.结果 23例患者均手术成功,随访3个月,均恢复良好,未发生并发症.结论 科学严谨的护理措施是提高悬吊式免气腹腹腔镜手术成功率,减少术后并发症,促进患者康复的重要保障.     

合并心肺血管疾病老年患者腹腔镜胆囊切除术的围手术期处理

目的探讨合并心肺血管疾病的老年患者行腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）的围手术期治疗经验。方法对2000年1月-2008年6月225例老年患者LC的术前准备及术中、术后处理进行回顾性分析。结果222例成功行LC,3例中转开腹手术。无胆管损伤、胆漏等并发症。7例术后出现肺部感染,3例出现泌尿系感染,经抗炎治疗后痊愈;心肌缺血改变3例。结论正确掌握手术适应证,术前充分准备,术中仔细操作,术中、术后周密的监护和处理,LC对老年患者是安全的。     

腹腔镜胆囊切除术与小切口胆囊切除术在老年患者中的应用体会

目的比较腹腔镜胆囊切除术（LC）与小切口胆囊切除术（MC）在老年患者中的临床效果,以指导临床选择应用。方法回顾性分析笔者所在医院2010年7月至2013年7月期间行LC（LC组,n=109）及MC（MC组,n=111）的老年患者的临床资料,比较2组术中和术后相关指标的差异。结果 LC组和MC组患者的手术时间〔（45.72±6.14）min比（40.67±6.02）min〕、术中出血量〔（10.18±3.31）mL比（11.13±2.93）mL〕、住院时间〔（9±5）d比（10±5）d〕及总并发症发生率〔28.4%（31/109）比31.5%（35/111）〕比较差异均无统计学意义（P〉0.05）;但LC组患者的术后疼痛程度轻、胃肠道功能恢复时间短〔（46.3±10.5）h比（71.4±9.8）h〕、住院费用较高〔（8 010±450）元比（4 800±680）元〕、切口感染发生率较低〔0（0）比15.3%（17/111）〕、肺部感染发生率较高〔17.4%（19/109）比9.9%（11/111）〕,P〈0.05。结论 LC对老年胆囊结石或胆囊炎患者具有更好的临床效果;但对心肺功能异常者,尤其是不能耐受全麻和气腹的患者选择MC更为合适,所以临床上应视患者具体情况加以选择。     

免气腹与气腹全腹腔镜下肝叶切除术的对比研究

目的探讨免气腹全腹腔镜下肝叶切除术应用的可行性。方法选择我院2008年5月～2009年12月资料完整的全腹腔镜下肝叶切除术22例,免气腹组11例(应用经穿刺孔8～14Fr导尿管腹壁牵拉技术),气腹组11例,进行回顾性对照研究,比较2组手术时间、术中出血量、术后腹腔引流量、术后胃肠功能恢复时间、术后恶心呕吐情况、术后住院时间、术后并发症,检测手术开始60min时动脉血CO2分压(PaCO2)、呼气末CO2分压(PETCO2)、中心静脉压(CVP)和气道压。结果2组手术均顺利,无中转开腹,无输血,术后恢复顺利。2组手术时间、术中出血量、术后腹腔引流量、肛门首次排气时间、术后住院时间、术后并发症差异均无显著性(P0.05)。免气腹组手术开始60min时PaCO2[(36.0±4.0)mmHgvs(43.9±3.8)mmHg,t=4.735,P=0.000],PETCO2[(31.3±2.8)mmHgvs(41.2±3.8)mmHg,t=6.978,P=0.000],CVP[(6.04±1.62)cmH2Ovs(7.81±1.66)cmH2O,t=2.533,P=0.020]和气道压[(17.1±2.5)cmH2Ovs(25.1±3.9)cmH2O,t=5.711,P=0.000]明显低于气腹组。结论经穿刺孔皮管腹壁提拉技术开展免气腹全腹腔镜下肝叶切除术可行,安全。     

肝硬化门脉高压患者腹腔镜胆囊切除术

目的:探讨合并肝硬化门脉高压(cirrhotic portal hypertension,CPH)患者腹腔镜胆囊切除术(cholecystectomy,LC)的手术适应症、可行性及手术难点.方法:回顾性研究37例患者的临床资料,术前、术中及术后的处理方法,观察术中出血量、手术时间、术后住院时间以及术后并发症.结果:手术完成35例,因Mirizzi综合征、胆管结石中转开腹各1例.手术时间(72.6±25.2)min.术中出血5～120 mL,平均55 mL.平均住院(3.0 1.5)d.术后4例发生并发症.结论:如能掌握手术的技术特点和围手术期处理,CPH患者LC是安全可行的.     

Laparoscopic Cholecystectomy in Obese Patients

Background: Laparoscopic cholecystectomy (LC) is the treatment of choice for gallstones. Obesity was initially considered a contraindication to this approach. The aim of this report is to review our experience with LC, to evaluate the role of BMI in the outcome. Methods: The records of 1,804 patients who underwent LC for symptomatic cholelithiasis from May 1992 to January 2004 were analyzed retrospectively. Patients were divided into 5 groups according to their BMI: ≤24.9, 25.0-29.9, 30.0-34.9, 35.0-39.9 and ≥40 kg/m². Results: Of the 1,804 patients [1,379 females (76.4%) and 425 males (23.6%)] who underwent LC, 431(23.9%), 924 (51.2%), 355 (19.7%), 68 (3.8%) and 26 (1.4%) had BMI values of ≤24.9, 25.0-29.9, 30.0-34.9, 35.0-39.9 and ≥40 kg/m², respectively. Conversion to open cholecystectomy was required in 94 patients (5.2%), and complications occurred in 39 patients (2.2%). There was no correlation between BMI and the conversion rate (P=0.593) and complication rate (P=0.944), while the hospital stay was similar between the groups with successful LC. The only significant difference was the longer operating time in the two obesity groups (P<0.001). Conclusions: LC is effective and safe in patients with morbid obesity. As it carried low risks of conversion and perioperative complications, we suggest that LC is the select approach for these patients. Moreover, the rapid mobilization and hospital discharge following LC may provide extra benefit to these patients.     

Laparoscopic Cholecystectomy in Cirrhotic Patients

Background and Objectives:

Gallstones are twice as common in cirrhotic patients as in the general population. Although laparoscopic cholecystectomy (LC) has become the gold standard for symptomatic gallstones, cirrhosis has been considered an absolute or relative contraindication. Many authors have reported on the safety of LC in cirrhotic patients. We reviewed our patients retrospectively and assessed the safety of LC in cirrhotic patients at a tertiary care hospital in Pakistan.

Methods:

From January 2003 to December 2005, a retrospective study was conducted at SU IV, Liaquat University of Medical & Health Sciences Jamshoro. All the cirrhotic patients with Child-Pugh class A and B cirrhosis undergoing LC were included in the study. Cirrhosis was diagnosed based on clinical, biochemical, ultrasonography, and intraoperative findings of the nodular liver and histopathological study.

Results:

Of 250 patients undergoing laparoscopic cholecystectomy, 20 (12.5%) were cirrhotic. Of these 20, 12 (60%) were Childs group A and 8 (40%) were group B. Thirty percent were hepatitis B positive, and 70% were hepatitis C positive. Preoperative diagnosis of cirrhosis was possible in 80% of cases, and 20% were diagnosed during surgery. Morbidity rate was 15% and mortality rate was 0%. Two patients developed postoperative ascites, and mean hospital stay was 2.8±0.1 days. Of the 20 cases, 2 (10%) were converted to open cholecystectomy. The mean operation time was 70.2±32.54 minutes.

Conclusion:

Laparoscopic cholecystectomy is an effective and safe treatment for symptomatic gallstone disease in select patients with Child-Pugh A and B cirrhosis. The advantages over open cholecystectomy are the lower morbidity rate and reduced hospital stay.