腹腔镜胆囊切除术后残余小胆囊的诊治和预防

目的 探讨腹腔镜胆囊切除术后残余小胆囊的诊治经验和预防措施.方法 回顾性分析新疆克拉玛依市中心医院自1994年12月至2007年12月收治的12例腹腔镜胆囊切除术后残余小胆囊的临床资料.结果 该组12例,腹腔镜胆囊切除术后残余小胆囊发生率为0.46%(12/2609),均经再次手术证实,其中伴结石者3例;经再次手术切除胆囊管残株、清除残余结石而治愈,效果良好.结论 腹腔镜胆日囊切除术后残余小胆囊首选B超或MRI检查,确诊后再次手术切除残株是治疗该病的有效方法.严格把握腹腔镜胆囊切除术的适应证,强调手术操作规范,是预防本病发生的关键.     

腹腔镜胆囊切除术后残余小胆囊的诊治和预防

目的 探讨腹腔镜胆囊切除术后残余小胆囊的诊治经验和预防措施.方法 回顾性分析新疆克拉玛依市中心医院自1994年12月至2007年12月收治的12例腹腔镜胆囊切除术后残余小胆囊的临床资料.结果 该组12例,腹腔镜胆囊切除术后残余小胆囊发生率为0.46%(12/2609),均经再次手术证实,其中伴结石者3例;经再次手术切除胆囊管残株、清除残余结石而治愈,效果良好.结论 腹腔镜胆日囊切除术后残余小胆囊首选B超或MRI检查,确诊后再次手术切除残株是治疗该病的有效方法.严格把握腹腔镜胆囊切除术的适应证,强调手术操作规范,是预防本病发生的关键.     

腹腔镜胆囊切除术后残株胆囊及胆囊管结石

目的探讨腹腔镜胆囊切除术后残株胆囊／胆囊管结石的原因、诊断、处理及预防方法。方法回顾总结我院 1992-2005年间收治的8例腹腔镜胆囊切除术后残株胆囊／胆囊管结石病例的临床资料。结果 8例病人术前经B超、MRI、 ERCP检查确诊后,均经再次手术治愈。残株胆囊结石2例;残株胆囊管结石6例,其中2例合并胆总管结石;2例行残余胆囊切除术,6例行残株胆囊管切除、其中4例附加胆总管切开探查和／或取石、T型管引流。随访1．1-13年,效果良好。结论判断失误是腹腔镜胆囊切除术后残株胆囊结石的主要原因,过长的炎性及畸形的胆囊管残留是腹腔镜胆囊切除术后残株胆囊管结石的主要原因;其症状和体征类似于结石性胆囊炎、合并胆管结石时可有黄疸;B超、CT、ERCP等检查可确诊;再次手术切除(或取出)残株胆囊／胆囊管(结石)是有效可靠的治疗方法;娴熟的腹腔镜技术、术中胆道造影、正确掌握中转开腹指征以及丰富的胆道外科经验是预防其发生的关键。     

57例胆囊术后残留病变的防治探讨

目的研究分析胆囊术后残留病变的治疗及预防经验。方法回顾性分析我院1999年4月—2006年7月期间收治57例胆囊术后残留病变者的临床资料。结果全部病人均再次手术治疗,残余小胆囊并炎症23例,残株结石29例,残株癌变4例,1例发生残端神经瘤。其中并发胆总管结石21例,并胆内胆管结石9例。结论重视胆囊切除术,合理处理胆囊管,合理应用腹腔镜手术,正确看待小切口手术是防治胆囊术后残留病变的关键。     

腹腔镜胆囊切除术后胆囊管结石残留的预防及处理

目的 探讨腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）术后胆囊管结石残留的预防及处理.方法 回顾性分析自2004年5月至2012年12月间共成功施行4 751例LC的临床资料.结果 135例LC术中采用胆囊管远端紧靠壶腹部施夹钛夹、切开胆囊管、自近端向远端挤压法取出胆囊管结石;其余4 616例中,12例术后发生胆囊管结石残留,4例经再次腹腔镜手术、8例经开腹手术成功取石,未再发生结石残留及其他严重并发症.结论 对胆囊管残余结石高风险病例,LC术中采用切开胆囊管、自近端向远端挤压法是预防术后胆囊管结石残留的有效方法.确诊LC术后胆囊管结石残留,应积极手术治疗,选择合适的病例再次经腹腔镜手术取出结石是安全可行的.     

胆囊切除术后残留胆囊病变28例临床分析

目的探讨胆囊切除术后残留胆囊病变的发病原因、诊断及治疗。方法对1993年1月~2003年12月28例胆囊切除术后残余胆囊病变患者的临床资料进行回顾性分析总结。结果本组27例均经再次手术切除残余胆囊,其中2例同时行胆总管切开取石、T管引流术,术后痊愈。1例胆囊残株癌行残余胆囊及胆总管切除肝肠吻合术,术后1年随访病人健在,术前症状消失。结论反复感染致使Calot三角严重粘连、胆囊颈管解剖变异、手术医生经验不足是造成手术残留的主要原因。首次胆囊切除术后原发症状仍然存在,结合B超、X线即可确诊。再次手术切除残余病变是治疗的有效手段。     

胆囊切除术后胆道病变22例临床分析

目的 探讨胆囊切除术后胆道病变的诊治及预防方法.方法 回顾性分析胆囊切除术后胆道病变22例的临床资料.结果 22例胆囊切除术后胆道病变经B型超声、ERCP、MRCP等诊断明确.10例残余胆囊、胆囊管结石及7例胆总管残余结石再次手术均治愈;3例意外胆囊癌中1例非手术治疗者于术后2个月死亡,另2例行肝楔形切除者已分别随访7个月和4个月,无复发现象;1例胆囊残株癌术后1年健在;1例胆囊残留癌再次手术后4个月死亡.结论 预防胆囊切除术后胆道病变重点在于术中仔细探查,准确地处理胆囊管,规范切除胆囊;正确对待胆囊大部切除术;正确看待小切口手术,以术野显露清楚为前提;慎重选择急性炎症期的手术时机.     

腹腔镜胆囊切除术后胆囊管残余结石5例报告

本文报道2007年8月～2009年6月腹腔镜胆囊切除术后胆囊管残余结石5例,发生率0.4%（5/1236）。3例行开腹手术,切除残余胆囊管取出残余结石;1例黄疸者行剖腹探查手术,术中证实为Mirizzi综合征Ⅱ型,切除残余胆囊管和结石,修补胆总管瘘口;1例冠心病者行腹腔镜残余胆囊管切除术。5例随访6～12个月,无腹痛、发热、黄疸。     

残株胆囊病变24例临床分析

目的 探讨胆囊切除术后胆囊残余病变的原因、治疗及预防方法.方法 回顾分析2000年1月至2007年12月间收治的24例胆囊切除术后残余病变的原因、类型、处理方法及效果.结果 24例均行再次手术.切除过长胆囊管或小胆囊,其中胆囊管或小胆囊内残余结石21例,残余胆囊合并有胆总管结石1例,加行胆总管切开取石,T型管引流,另2例为残余胆囊.术后恢复良好,均治愈.切除标本送病理检查,无肿瘤及恶变.结论 首次手术前全面、系统的影像学检查,合理掌握胆囊切除术的手术时机,术中辩清胆总管、肝总管、胆囊管三管之间的关系,术中仔细探查、规范切除胆囊是预防胆囊残余病变的关键.     

腹腔镜胆囊切除术后胆囊管残留结石或结石再发的治疗

目的 探讨腹腔镜胆囊切除术后胆囊管残留结石或结石再发的发生原因和处理方法.方法 回顾性分析2004年10月至2012年10月腹腔镜胆囊切除术后胆囊管残余结石或结石再发5例的治疗情况.结果 5例中影像检查均有胆囊管结石,测量胆囊管长度为2～7 cm,2例胆囊管远端明显扩张.4例再次手术治愈;1例经保守治疗后好转出院,9个月后死于胆道感染合并重症胰腺炎.结论 腹腔镜胆囊切除术中胆囊管残留过长是导致术后胆囊管结石残留或结石复发的主要原因,一旦发生应积极手术治疗.     

腹腔镜胆囊切除术后残余胆囊结石的外科处理

目的探讨腹腔镜胆囊切除术后残余胆囊结石的治疗和预防方法。方法回顾分析16例腹腔镜胆囊切除术后残余胆囊结石患者的诊治经过。结果结合彩超、MRCP、ERCP等检查方法均可确定诊断,通过开腹或腹腔镜下残余胆囊切除术,术后患者临床症状均有效缓解,无严重并发症。结论对于残余胆囊应该重视初次手术中的预防。腹腔镜下残余胆囊切除术安全可靠。当合并胆总管结石时,可联合内镜和腹腔镜分次治疗。术中胆道造影或胆道镜检查可增加手术安全。     

困难性腹腔镜胆囊切除术手术方法探讨

目的探讨困难性腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）的手术处理技巧。方法回顾分析我院2006年3月～2008年12月完成的201例困难性LC手术资料,包括胆囊周围包囊粘连107例,胆囊三角区致密粘连、解剖困难75例,胆囊颈部结石38例,胆囊化脓坏疽11例,胆囊萎缩18例,上腹部手术史17例。结果193例完成腹腔镜手术,8例（4.0%）中转开腹,原因包括：3例胆囊三角区出血止血困难;2例胆囊与结肠、胃及十二指肠粘连致密无法分离显露胆囊,胆囊坏疽;2例胆囊管近汇合部后壁轻度撕裂伤致胆漏;1例胆囊三角区呈＂冰冻＂状难以解剖。无胆管损伤及术中大出血。术后并发症3例（1.5%）,包括胆囊三角区出血1例,机械性肠梗阻二次手术1例,肺部感染、呼吸功能衰竭1例,均治愈。全组无死亡。结论对困难性LC,应始终遵循＂解剖紧贴胆囊,切前辨清关系,钝锐交替分离,顺逆结合切除＂的原则,有上腹部手术史则用开放法建立气腹,分离腹腔粘连。     

以胆囊排空障碍为特点的慢性非结石性胆囊炎的诊治分析:附42例

目的 探讨以胆囊排空障碍为特点的慢性非结石性胆囊炎的诊断方法与外科治疗.方法 选取昆明医学院第二附属医院2006年1月至2008年12月收治的慢性非结石性胆囊炎42例临床资料进行分析.将其分为腹腔镜胆囊切除术组20例,非手术治疗组22例,比较其疗效.结果 42例均通过临床症状、B超、胆囊收缩功能检查、纤维胃镜、磁共振胰胆管成像得以诊断;均存在胆囊排空障碍,其中腹腔镜胆囊切除术组,术后随访18例,未再出现临床症状,失访2例;非手术治疗组,随访21例,临床症状反复发作19例,失访1例.腹腔镜胆囊切除术效果明显优于非手术治疗(P＜0.05).结论 以胆囊排空障碍为特点的慢性非结石胆囊炎可以通过临床症状、胆囊收缩功能检查、MRCP得以诊断,治疗方法以腹腔镜胆囊切除术为佳.

Abstract：

Objective To investigate the diagnosis and surgical treatment of chronic acalculous cholecystitis characterized by absence of gallbladder wall contractability. Methods The clinical data of 42 patients with chronic acalculous cholecystitis in our hospital from January 2006 to December 2008were analysed. The patients were grouped into two groups: laparoscopic cholecystectomy (LC) group in 20 and non-surgical group in 22. The patients' symptoms on follow-up in the two groups were compared. Results The 42 patients with chronic acalculous cholecystitis were diagnosed by symptoms,ultrasound, fatty meal gallbladder contractability studies under ultrasound, fiber optic gastroscopy and magnetic resonance cholangiopancreatography (MRCP). In all patients, there was a complete absence of gallbladder wall contractability. In the LC groups, 20 patients received LC. 18 patients were followed up, and there were no symptoms. Two patients were lost to follow up. In the non-surgical group, 22 patients received non-surgical treatment. In 21 patients who were followed up, 19 patients had symptoms. One patient was lost to follow up. There was a significant difference between the LC group and the non-surgical group (P＜0.05). Conclusions Chronic acalculous cholecystitis characterized by absence of gallbladder wall contractability could be diagnosed by symptoms, ultrasound, fatty meal gallbladder contractability studies under untrasound, and MRCP. The optimal treatment of chronic acalculous cholecystitis characterized by absence of gallbladder wall contractability is LC.     

Can early laparoscopic cholecystectomy be the optimal management of cholecystitis with gallbladder perforation? A single institute experience of 74 cases

Background

Gallbladder perforation is a rare but serious complication of cholecystitis. It was usually managed by percutaneous gallbladder drainage (PTGBD) followed by elective cholecystectomy. However, evidences are emerging that early laparoscopic cholecystectomy (LC) is still feasible under these conditions. We hypothesized that early LC may have comparable surgical results as to those of PTGBD?+?elective LC.

Material and methods

From January 2005 to October 2011, patients admitted to China Medical University Hospital with a diagnosis of perforated cholecystitis were retrospectively reviewed. The diagnosis of gallbladder perforation was made by image and/or intraoperative findings. Those patients who had unstable hemodynamics that were not fitted for general anesthesia or those who had concomitant major operations were excluded. Patients were divided into three groups: early open cholecystectomy (group 1), early LC (group 2), and PTGBD followed by elective LC (group 3). The demographic features, surgical results, and patient outcome were analyzed and compared between groups.

Results

A total of 74 patients were included. All patients had similar demographic features except that patients in group 2 were younger (62 vs. 72 and 73.5?years) compared with group 1 and group 3 (p?=?0.016). There were no differences in terms of operative time, blood loss, conversion, and complication rate between three groups. The length of hospital stay (LOS) was significant shorter in group 2 patients compared with that of groups 1 and 3.

Conclusions

Although PTGBD followed by elective LC was still the mainstay for the treatment of gallbladder perforation, early LC had comparable surgical outcomes as that of PTGBD?+?LC but with a significantly shorter LOS. Early LC should be considered the optimal treatment for gallbladder perforation, and PTGBD?+?LC can be preserved for those who carried a high risk of operation.     

急性胆囊炎腹腔镜胆囊切除术420例报告

目的:探讨腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)治疗急性胆囊炎的可行性及安全性。方法:回顾分析2000年2月至2011年8月为420例急性胆囊炎患者行LC的临床资料。结果:402例顺利完成LC。18例中转开腹行胆囊切除术,其中Mirizzi综合征5例,胆囊三角"冰冻样"粘连12例,1例胆总管损伤行胆管修补及T管引流术,术后6个月拔除T管。5例术后发生胆漏,均保守治疗痊愈。术后随访6～12个月,无胆管狭窄、胆管残余结石、残余小胆囊等严重并发症发生。结论:只要术者熟练掌握操作技巧,提高术中应变能力,为急性胆囊炎患者行LC是安全可行的。     

Gallbladder carcinoma and laparoscopic cholecystectomy. An emergent problem

BACKGROUND: Gallbladder cancer (GC) is reported in 1.5-3% of cholecystectomies. Since the introduction of laparoscopic surgery, cholecystectomies have increased and occult GC may therefore be more frequent. METHODS: Here we conduct a retrospective study on a series of 1200 LC performed between January 1991 and December 1998 at our Institution, to determine whether there was an increase in GC. We also evaluated the risk factors for this outcome and the possibilities of treatment, in case of unsuspected GC discovered after LC at histological examination. Seven cases of GC undiagnosed before surgery (0.6% of the study population) were submitted to LC (against 0.3% GC discovered after open surgery). The clinical course depended on the histopathologic stage of the cancer. RESULTS: After a median follow-up of 18 months (range 12-48), 2 pT1 patients were alive and well, 2 pT2 patients were alive and disease free (in 1 case after a surgical removal of a trocar site metastasis appeared 6 months after LC). The other 3 patients died, 2 (1 pT2 and 1 pT3) after an additional resection of the liver bed with lymph node dissection, due to peritoneal dissemination of the disease. In 2 cases we found a gallbladder polyp pre and intraoperatively, which proved to be a carcinoma. CONCLUSIONS: Undiagnosed GC is on the increase with the introduction of LC. Polypoid lesions of the gallbladder, age > 70 years: a long history of stones and a thickened gallbladder wall all represent significant risk factors. If one or more is present, examination of the gallbladder and a frozen section are recommended.     

腹腔镜胆囊切除术中增粗胆囊管处理方法的探讨

目的：探讨腹腔镜胆囊切除术中胆囊管增粗的处理方法.方法：自2002年11月至2004年10月,对27例胆囊管增粗患者行腹腔镜胆囊切除术,其中胆囊管直径0.4～0.6cm 16例,0.6～0.8cm 6例,＞0.8cm 5例.在腹腔镜胆囊切除术中采用阶梯施夹法2例、大号钛夹法10例、胆囊管结扎后施夹法10例、胆囊管结扎法5例等4种方法处理胆囊管,常规放置腹腔引流管.结果：27例无并发症发生,均痊愈出院.结论：在腹腔镜胆囊切除术中应采用个体化的方法处理增粗胆囊管.     

Iatrogenic perforation of the gallbladder during laparoscopic cholecystectomy does not influence the prognosis. Prospective study

BACKGROUND: Perforation of the gallbladder and spillage of gallstones frequently occur in laparoscopic cholecystectomy. As stones may be lost and as spilled bile is known to be contaminated, influence on morbidity may be expected. AIMS: To evaluate the immediate and late consequences on morbidity of peroperative gallbladder perforation during laparoscopic cholecystectomy (LC) in an universitary hospital center. PATIENTS AND METHODS: One hundred and twenty one LC were prospectively evaluated with a mean follow-up of 30 months. Elective operations on 30 men and 91 women with a mean age of 56.4 years (18-85) were carried out for symptomatic cholecystolithiasis in 97 cases (80%), and in 24 cases for complicated cholecystolithiasis. The "french technique" was used for all LC, with systematic intra-operative cholangiography and ultra Sonography. Thirty-seven (30.5%) LC were performed by surgical trainees, 84 LC by confirmed surgeons. The consequences of ultra-operative gallbladder perforation were evaluated in the immediate postoperative period, especially for septic complications, and thereafter, patients were followed up 1, 6, 12 and 24 months postoperatively. RESULTS: Ultra-operative gallbladder perforation occurred in 24 cases (20%), in 83.3% during gallbladder dissection. Gallstone spillage occurred six times, and all spilled stones were removed. Gallbladder perforation was more frequent (but non significant) in acute cholecystitis (25 vs 19%, ns). A clear correlation to the skill and experience of the surgeon is shown (32.4 vs 14.2%, P =0.01). Gallbladder perforation is accompanied by an elevated (nonsignificant) postoperative morbidity (16.6 vs 7.2%, P =0.62) which is, in fact related to older patient and more acute cholecystitis in this group. No reoperations were necessary. One and two years follow-up revealed no long-term complications specially due to lost gallstones. CONCLUSION: Peroperative gallbladder perforation during LC carries no morbidity, provided a total and complete recuperation of gallstones spilled and local treatment of bile contamination with local irrigation and antibiotics. This complication is correlated to the surgeon's skill and experience.