急诊腹腔镜胆囊切除术中复杂情况处理的探讨

目的探讨急诊腹腔镜胆囊切除手术中几种复杂情况的处理。方法回顾性分析总结该院2004-2005年操作困难的腹腔镜胆囊切除术72例。结果手术时间30～300min，平均50min：出血量10～350mL，平均30mL；引流管留置1～3d，引流量20～300mL，平均约100mL；术后住院时间2～6d；所有病例无中转开腹手术和死亡；迟发性胆漏及术后发热各1例，均保守治疗痊愈。结论在急诊腹腔镜胆囊切除术中常见Calot三角解剖形态改变、动脉出血、胆囊管显露和胆囊完全切除困难等复杂情况。对胆道系统解剖的熟悉及娴熟的手术操作技巧是解决这些复杂情况的关键。     

困难型腹腔镜胆囊切除术的手术处理及分析

[目的]探讨困难型腹腔镜胆囊切除术的困难原因及处理方法.[方法]回顾性分析2005年3月至2007年3月本科开展66例困难型腹腔镜胆囊切除术的临床资料.均采用无选择性切除,对操作技巧及处理方法进行探讨及分析.[结果]手术困难原因:胆囊颈部结石嵌顿45例(占68.2%),胆囊萎缩9例(占13.6%),有上腹部手术史且胆囊与邻近脏器粘连7例(占10.6%),合并有肝硬化门脉高压症2例(占3%),肝外胆道变异3例(占4.5%),成功63例,中转开腹3例,成功率95.5%,无出血、胆管损伤及死亡病例.[结论]多种情况导致Calot三角区粘连为常见困难原因,Calot三角区粘连处理直接影响手术成功率和并发症发生,在处理Calot三角区粘连较重、解剖不清时,要坚持以"冷分离"为主,困难的腹腔镜胆囊切除也能安全完成.     

腹腔镜治疗充填型结石性胆囊炎48例体会

[目的]探讨腹腔镜治疗胆囊充填型结石并萎缩性胆囊炎的手术技巧和可行性.[方法]回顾分析本院2002年6月至2004年6月48例充填型结石并萎缩性胆囊炎的腹腔镜胆囊切除术术中处理技巧及注意事项.[结果]48例腹腔镜胆囊切除术中中转开腹2例,腹腔镜胆囊切除术发生术后胆瘘3例、无胆道损伤及术后出血等并发症发生,所有患者均痊愈出院.[结论]腹腔镜治疗充填型结石性胆囊炎在临床是可行的.     

针型腹腔镜胆囊切除术139例报告

目的 :探讨针型腹腔镜胆囊切除术穿刺孔的选择、Calot三角解剖、胆囊管及胆囊动脉的结扎及标本取出。方法 :采用针型腹腔镜胆囊切除 13 9例 ,胆囊结石 87例 ,胆囊炎 13例 ,胆囊息肉 3 9例。结果 :13 6例针型腹腔镜下完成 ,3例中转为普通腹腔镜手术 ,13 9例均治愈出院。结论 :针型腹腔镜手术病人的创伤更小 ,术后恢复更快 ,但有一定的适应证     

困难型胆囊结石56例腹腔镜胆囊切除术诊疗体会

目的 :探讨困难型胆囊结石腹腔镜胆囊切除术手术技巧 ;方法 :41 9例腹腔镜胆囊切除术患者中 ,回顾性分析其中 5 6例困难型胆囊结石的手术及并发症的防治要点 ;结果 :5 6例困难型胆囊结石 5 3例顺利完成腹腔镜胆囊切除术 ,3例因出血、胆道变异和广泛粘连而中转手术 ,其中 4例胆囊部分切除 ,无胆漏、胆道损伤发生 ;结论 :腹腔镜胆囊切除术完成困难型胆囊结石手术适应证不断扩大 ,能够顺利完成 ,效果满意。     

腹腔镜胆囊切除术中困难原因分析与处理

目的 探讨腹腔镜胆囊切除术(LC)的困难原因及处理技巧.方法 回顾性分析2004年7月～2009年11月在该院及外院会诊中施行的104例困难腹腔镜胆囊切除术的手术资料,针对不同情况采用薄层解剖法、吸引器推剥法、镜下缝合以及结合术中胆道造影术等技巧.结果 全组104例,103例成功施行腹腔镜胆囊切除术,1例因胆囊三角疤痕组织难以分离而中转开腹,无胆漏、出血等严重并发症发生,全部治愈出院.结论 对于困难的腹腔镜胆囊切除可采用薄层解剖法、推剥法及镜下缝合技术结合开腹手术理念可顺利完成手术.     

腹腔镜下困难胆囊切除术的体会

目的探讨腹腔镜下行困难胆囊切除术的方法和手术原则。方法对86例困难的腹腔镜胆囊切除术的手术技术进行总结。结果 86例患者均行腹腔镜胆囊切除术,中转开腹2例,平均手术时间75 min,术中出血量平均90ml,术后平均住院时间3.6 d,未出现严重并发症。结论采用适当的手术技术,困难的胆囊在腹腔镜下切除是安全的。     

腹腔镜胆囊切除术9603例临床分析

目的 总结该院9603例腹腔镜胆囊切除术(LC)的治疗经验,探讨腹腔镜胆囊切除术的术中、术后并发症的预防和处理.方法 回顾性分析9603例腹腔镜胆囊切除术手术的临床资料.结果 全组无死亡病例.术后出血3例,2例急诊手术后治愈,1例保守治疗治愈;胆管损伤2例,1例术中行对端吻合后治愈,1例术后再次手术行肝门胆管空场Rouxen-Y吻合术后治愈;术后胆漏5例,2例行急诊手术后治愈,1例经穿刺引流治愈;胆总管残余结石4例.结论 腹腔镜胆囊切除术应尽量避免并发症的发生,一旦发生并发症应及时、妥善处理.术中遇到解剖关系不清、操作困难的复杂病例、应果断中转开腹.     

后侧分离半体解剖在困难腹腔镜胆囊切除术中的应用

目的探讨困难腹腔镜胆囊切除术(LC)的处理。方法回顾分析2002年11月～2007年5月86例困难LC的临床资料,探讨手术的方法和技巧。结果LC完成82例,中转开腹4例,未发生胆管损伤等严重并发症。结论后侧分离半体解剖在困难腹腔镜胆囊切除术中有独特的优势。     

腹腔镜解剖性脾切除术31例经验

目的 探讨腹腔镜解剖性脾切除手术的方法 与优点.方法 回顾性分析31例接受了腹腔镜解剖性脾切除术患者的临床资料.结果 27例顺利完成手术,出血5～300 mL,手术时间50～250 min.术后5～9 d患者出院,无并发症发生.1例术中因脾血管出血中转开腹手术.1例为手辅助脾切除术.1例门静脉高压患者切下脾后开腹止血.同时行门奇静脉断流术2例.同时行腹腔镜胆囊切除术(LC)8例.1例行胆囊切除并脾下极部分切除术.结论 腹腔镜解剖性脾切除术可以明显减少术中出血的危险,是一种安全且效果良好的手术.     

腹腔镜胆囊切除术中转开腹指征的探讨

目的：探讨腹腔镜胆囊切除术中转开腹指征，方法：回顾性分析10例腹腔镜胆囊切除术中转开腹病例。结果：10例中转开腹病人术后恢复良好。结论：对腹腔镜手术有困难的病例。及时中转能保证病人的安全，降低手术风险，减少并发症。     

腹腔镜胆囊切除术中转开腹胆囊切除术29例原因分析

目的：探讨腹腔镜胆囊切除术后中转开腹的时机。方法：分析536例腹腔镜手术，中转手术29例。结果：发生在腹腔镜胆囊切除术早期9例，同期腹腔镜胆囊切除术102例，中转率8．824％。发生在腹腔镜胆囊切除术中期13例，同期腹腔镜胆囊切除术224例，中转率5．804％。发生在腹腔镜胆囊切除术后期7例，同期腹腔镜胆囊切除术210例，中转率3.333％。结论：腹腔镜胆囊切除术治疗中若出血困难而转开腹手术，并不是腹腔镜胆囊切除术的失败，而是保证患者安全和提高手术质量所必须的。中转手术是患者安全的保证。     

腹腔镜处理腹腔镜胆囊切除术后胆漏的诊治体会

目的探讨腹腔镜处理腹腔镜胆囊切除术后胆漏的原因及防治方法。方法对12例腹腔镜胆囊切除术后胆漏患者的临床资料诊治进行回顾性分析。结果4例患者经非手术治疗痊愈；8例经再次行腹腔镜探查术，其中胆囊管残端钛夹脱落或夹闭不全4例，经重新结扎胆囊管并置腹腔引流后治愈；肝外胆管撕裂伤2例，经腹腔镜下缝合修补置腹腔引流治愈；迷走胆管损伤致胆漏者1例，采用钛夹夹闭治愈；胆囊切除加胆总管切开取石胆总管一期缝合针眼渗漏胆汁l例，拆除胆总管缝线置“T”管引流，一个月后拔除“T”管治愈。结论胆囊管残端钛夹脱落或夹闭不全、肝外胆管或迷走胆管损伤是腹腔镜胆囊切除术后胆漏的主要原因，若腹腔引流通畅，无腹膜炎体征，引流胆汁每日不超过200ml并逐日减少可经非手术治疗治愈，其他可再次行腹腔镜探查予以处理，但关键还在于预防。     

腹腔镜胆囊切除术前超声检查的实用价值

目的探讨腹腔镜胆囊切除术前超声检查的实用价值。方法对临床施行腹腔镜胆囊切除术的262例患者进行回顾性分析,将其术前超声诊断与术后病理诊断结果及术中证实手术困难因素进行回顾性对照分析总结。结果262例施行腹腔镜胆囊切除术的患者,其术前超声诊断结果与术后病理诊断结果符合率98．1％,术中证实手术困难因素5种计27例,占10．3％;术中转开腹9例,占3．4％;胆管受损1例,占0．38％;手术成功率96．1％。结论腹腔镜胆囊切除术前超声检查对临床提供了重要的诊断与指导价值。     

34例Mirizzi综合征的术中诊断和分型治疗

目的探讨Mirizzi综合征的病理特点及合理的诊断与治疗方法。方法对经手术证实的34例Mifizzi综合征的临床资料进行回顾性分析。结果34例（含术前明确诊断者5例）均采用手术治疗。手术方式：采用腹腔镜或开腹胆囊大部分切除7例,胆囊切除11例,胆囊切除加胆总管探查7例,用胆囊瓣瘘口修补加胆总管探查6例,肝圆韧带瘘口修补加胆总管探查1例,胆囊切除加胆肠内引流术2例。结论Mirizzi综合征术前诊断困难,术中明确诊断是防止胆道损伤的关键,治疗应根据不同的病理类型选择相应的手术方法。     

Failed or difficult laparoscopic cholecystectomy: Can preoperative ultrasonography identify potential problems?

A prospective study was performed to assess the role of preoperative ultrasonography in predicting failed or difficult laparoscopic cholecystectomy. Fifty patients underwent detailed preoperative ultrasound examinations. The number and size of calculi, evidence of acute or chronic cholecystitis, gallbladder morphology, and the presence or absence of aberrant anatomy were documented. A comparison was made of the surgical outcome and the ultrasound findings in each patient. Six patients were converted to open cholecystectomy because of inflammatory changes in the gallbladder. The preoperative ultrasound studies in 5 of these patients demonstrated evidence of cholecystitis and cholelithiasis. Gallbladder wall thickening and contraction were also seen. Five gallbladder resections had intraoperative difficulties; preoperative ultrasonography demonstrated a thickened gallbladder wall in 2. Of 31 uneventful cases, 7 had evidence of gallbladder wall thickening and/or contraction. There were no ultrasound features that identified between the unsuccessful, difficult, or uneventful laparoscopic cholecystectomies. We conclude that detailed preoperative ultrasound evaluation of the gallbladder in patients destined for laparoscopic cholecystectomy is of little value in screening for difficult or unsuitable cases. © 1994 John Wiley & Sons, Inc.     

Sonographic features of intra-abdominal abscess caused by spilled stones during laparoscopic cholecystectomy

Spillage of stones into the abdominal cavity resulting from perforation of the gallbladder is one of the common complications of laparoscopic cholecystectomy. Although many surgeons know that stones left in the abdominal cavity can cause late visceral abscess requiring surgical treatment, the sonographic features of such abscesses have not yet to be thoroughly investigated. We investigated the sonographic features of intra-abdominal abscesses caused by spilled stones after laparoscopic cholecystectomy using Hitachi Model EUB-525 (3.5 MHz) and Aloka Model SSD-5500 (3.75 MHz) ultrasound systems. Two thousand thirty-six laparoscopic cholecystectomy procedures were carried out at this institution from 1990 through 2001. During this period, we encountered seven cases of intra-abdominal abscess. Three of these cases were symptomatic, but abscess, granulation, or both, were found incidentally by ultrasonography in the other four patients during routine annual health examinations. Laparotomy and open drainage of pus and gallstones from the intra-abdominal abscess were necessary in five cases. Ultrasonography revealed a mass in six of the seven patients. The abscesses were located in either the right subphrenic or subhepatic space on the surface of the liver and were sometimes difficult to distinguish from liver tumors. Ultrasound showed the abscesses as oval, low-echoic, solid masses with posterior enhancement. They ranged from 20 to 58 mm in diameter, had clear margins and highly echoic peripheral rims, and showed lateral shadowing. The lesions also contained several highly echoic spots with acoustic shadows that were thought to be the spilled stones. We conclude that visceral abscess should be considered after laparoscopic cholecystectomy, and that careful observation using ultrasonography is required, especially when the gallbladder is perforated and bile and stones have spilled out.     

腹腔镜胆囊切除术后迟发性胆漏的特点和防治

目的 探讨腹腔镜胆囊切除术后迟发性胆漏的特点、治疗措施及预防手段.方法 对7例腹腔镜胆囊切除术后迟发性胆漏患者的临床资料进行分析.结果 该组病例中热电效应引起的胆管穿孔性损伤6例,迷走胆管漏1例,5例行手术治疗,2例经ERCP＋ENBD治愈.结论 对于手术操作者来说,过多地使用单极高频电钩电凝、电切产生的热电效应,造成损伤的胆管壁组织脱痂、坏死、穿孔,是造成腹腔镜胆囊切除术后迟发性胆漏发生的主要原因,ERCP＋ENBD是治疗腹腔镜胆囊切除术后迟发性胆漏的有效手段.     

超声刀结合术中胆道造影行腹腔镜胆囊大部切除术23例临床分析

目的:探讨超声刀结合术中胆道造影行腹腔镜胆囊大部切除术的手术适应症和安全性.方法:回顾性分析我院2010年1月～2011年3月行超声刀结合术中胆道造影腹腔镜胆囊大部切除术23例患者的临床资料.结果:全组病例均于术后第2天拔出腹腔引流管,术后第3天出院,随访至少3个月,无胆漏、出血或胆管损伤等围手术期并发症发生.结论:超声刀结合术中胆道造影行胆囊大部切除术对Calot三角解剖困难的手术安全性高.     

急性胆囊炎行腹腔镜胆囊切除47例分析

目的 探讨急性胆囊炎行腹腔镜胆囊切除术的可行性。方法 回顾分析了急性胆囊炎行腹腔镜胆囊切除术47例病人术中，术后出现的并发症及并发症的预防和处理。结果 手术成功率为87.23%。胆瘘1例，戳口感染2例。结论 虽然急笥胆囊炎行腹腔镜手术变异多，难度大，但只要严格掌握适应症，仍有较高的手术成功率。