Blunt Dissection: A Solution to Prevent Bile Duct Injury in Laparoscopic Cholecystectomy

Background:

Laparoscopic cholecystectomy (LC) has been a standard operation and replaced the open cholecystectomy (OC) rapidly because the technique resulted in less pain, smaller incision, and faster recovery. This study was to evaluate the value of blunt dissection in preventing bile duct injury (BDI) in laparoscopic cholecystectomy (LC).

Methods:

From 2003 to 2015, LC was performed on 21,497 patients, 7470 males and 14,027 females, age 50.3 years (14–84 years). The Calot''s triangle was bluntly dissected and each duct in Calot''s triangle was identified before transecting the cystic duct.

Results:

Two hundred and thirty-nine patients (1.1%) were converted to open procedures. The postoperative hospital stay was 2.1 (0–158) days, and cases (46%) had hospitalization days of 1 day or less, and 92.8% had hospitalization days of 3 days or less; BDI was occurred in 20 cases (0.09%) including 6 cases of common BDI, 2 cases of common hepatic duct injury, 1 case of right hepatic duct injury, 1 case of accessory right hepatic duct, 1 case of aberrant BDI 1 case of biliary stricture, 1 case of biliary duct perforation, 3 cases of hemobilia, and 4 cases of bile leakage.

Conclusion:

Exposing Calot''s triangle by blunt dissection in laparoscopic cholecystectomy could prevent intraoperative BDI.     

Suspected bile duct injuries and appropriate early referral can reduce chances of litigation

Bile duct injury following laparoscopic cholecystectomy is one of the most feared complications related to performing a cholecystectomy. Early identification and repair can be life saving for patients with bile duct injuries. Since the early 1990s, laparoscopic cholecystecomy (LC) has replaced open cholecystectomy as the preferred treatment of symptomatic cholethiasis, biliary dyskinesia, and cholecystitis. LC has decreased the length of hospital stay and post-operative pain and resulted in a subsequent faster return to normal daily activities; nonetheless, LC has a higher incidence in bile duct injury as compared to open cholecystectomy. Nearly all studies report the incidence of bile duct injury following open cholecystectomy between 0.1% and 0.2%. In comparison, LC has a reported incidence of bile duct injury between 0.4% and 0.7%. The aim of this article is to review our initial experience with work-up and repair of bile duct injuries following LC performed at outside facilities and referred to the University of Mississippi Medical Center (UMMC) for definitive therapy. We will also review the classification of these injuries, preferred methods of diagnosis, and benefits of early treatment as well as factors that frequently lead to litigation following bile duct injury.     

腹腔镜胆囊切除术致胆管损伤的临床分析

目的 观察并分析腹腔镜胆囊切除术致胆管损伤的危险因素,以指导临床做好预防工作. 方法 该次研究对象整群选取2013年4月—2015年4期间该院收治的320例腹腔镜胆囊切除术病例,回顾性分析入组病例临床资料,总结胆管损伤的影响因素. 结果 入组320例患者中胆管损伤共计11例,经临床对症救治后治愈9例,另行肝门胆管-空肠Roux-en-Y吻合的1例患者术后伴有发热以及胆漏症状, 临床采取引流处理后治愈;1例胆管损伤病例于术后发现,行肝门胆管-空肠Roux-en-Y吻合术时发生胆漏,给予引流后治愈.结论 腹腔镜胆囊切除术操作中胆管损伤较为常见,术者应严格、系统地训练腹腔镜操作技术,熟悉并掌握胆管解剖以及变异知识,手术过程中应高度警惕胆管损伤,细致辨认肝外三管,做好医源性胆管损伤的预防工作.     

Retrospective Study of Injuries in Military Parachuting

Background

This paper analyses the rate and patterns of parachuting injuries at the Sultans Oman Parachute Unit (SOPRA) in Oman.

Methods

Data on 150 patients referred to Rustaq Regional Referral Hospital was collected and analysed. The injuries were defined as severe (fractures, dislocation, head trauma) or minor (contusion, bruises, sprains).

Result

The rate of severe injuries was 9 % and ankle fractures were the commonest. The minor injury rate was 13.5%. The injury rate increased in relation to age (p < 0.001). The type and possible mechanisms of injury are discussed with the recommendation for reducing the injury rates.

Conclusion

We conclude that our data compares favourably with other studies except for higher incidence of severe injuries.Key Words: Parachute, Paratrooper, Parachuting injuries     

Bile duct injuries in open and laparoscopic cholecystectomy: Apples and oranges

Bile duct injuries are potentially devastating for the patient and the surgeon. Most bile duct injuries probably occur during the initial 12-15 cases of laparoscopic cholecystectomy done by any one surgeon^(8,15). It is imperative therefore that surgeons in training or who are new to this technique are adequately supervised during this period. There seems to be an increased incidence of bile duct injury with the laparoscopic technique (0.6% compared with 0.2%). Laparoscopic bile duct injuries however, may be more common but less serious compared with the open approach. A high proportion of laparoscopic injuries are injures in continuity, which may be managed without recourse to laparotomy. The incidence of severe injury requiring a hepaticoenterostomy does not seem to have increased, though as yet we cannot comment on the incidence of late duct strictures from the laparoscopic approach. Laser and diathermy injuries are also more common with the laparoscopic procedure and the high reported incidence of bile leaks must be carefully analysed. It has been suggested that large scale audit is more likely to reflect the true incidence of bile duct injury due to under-reporting of a relatively uncommon problem in published series⁽⁴³⁾. Analysis of bile duct injuries should therefore take into account different rates in reported and audit series, bile leaks, probable increased primary diagnosis at the original laparoscopic cholecystectomy, and the learning curve as well as new mechanisms of diathermy or laser injury. With comparative analysis and experience the long term incidence of bile duct injuries may be similar to that after the open procedure, and indeed may even be less in some centres⁽⁵⁰⁾.     

医源性肝外胆道损伤26例分析

目的：为预防医源性肝外胆管损伤，探讨损伤的原因、预防措施和治疗方法：方法：收集我院近15年因肝胆胰手术腹腔镜胆囊切除等肝外胆道损伤共26例进行分析。结果：行胆囊切除术20例，腹腔镜胆囊切除术6例。手术致肝总管横断2例，胆总管横断7例，胆总管结扎4例，胆总管裂伤9例，右肝管裂伤2例，副肝管横断2例。结论：胆道周围的炎症水肿，萎缩性胆囊炎、Mirizzi综合症和高位胆囊手术时易发生胆管损伤；门静脉高压症和术中出血，胆管损伤的机会增大；术中经验不足或过于自信亦是造成胆管损伤的重要原因。肝胆胰手术的经验积累，克服盲目自信，术中规范操作可以降低肝胆外道损伤的发生率。     

腹腔镜胆囊切除术后胆漏及胆管损伤的临床分析与对策探讨

目的:探讨腹腔镜胆囊切除术后胆漏及胆管损伤的常见原因及临床诊断和治疗方法.方法:回顾性分析采用腹腔镜胆囊切除手术治疗疾病后出现胆漏及胆管损伤的11例患者资料,总结其发生并发症的原因,分析临床诊治措施.结果:11例患者中,4例患者为术后24h内发现,7例患者为术后48h内发现.患者损伤原因主要包括肝外胆管损伤3例,胆囊管残段钛夹脱落1例,迷走胆管损伤3例,胆总管热损伤4例.所有患者均痊愈出院.结论:对腹腔镜胆囊切除术后发生胆漏及胆管损伤的重点在于预防,做到早期发现,积极治疗,以促进患者早日康复.     

胆囊切除术致高位胆管损伤的原因及手术处理

目的探讨胆囊切除致高位胆管损伤的原因、处理方法及注意事项.方法回顾性分析1998年1月至2005年12月对12例胆囊切除致高位胆管损伤病例的临床资料.12例中腹腔镜胆囊切除(LC)7例,开腹胆囊切除(OC)5例.肝总管横断伤4例,其中2例对端吻合术,另2例胆管缺损一段者,采用高位胆肠吻合术;右肝管损伤2例,1例行右肝管修补内置支架管引流,另1例行右肝管空肠吻合术;左右肝管汇合部部分切除及汇合部完全切除各3例,采用"肝门板"下降、胆管整形,胆管空肠超高位吻合.结果无手术死亡,随访5个月至5年,无黄疸及胆道感染等并发症.结论:高位胆管损伤一旦发生应及时处理,根据术中损伤类型,采取不同的处理方法,可获得满意的效果.     

医源性胆管损伤

随着腹腔镜胆囊切除的普及,胆管损伤发生率约在0.19%～0.7%,开腹手术约为0.4%。发生原因主要有肝门和Calot三角解剖不清、胆囊炎症、解剖变异、电凝使用不当、技术失误、术中出血等。按照中华医学会外科分会胆管外科学组编写的《胆管损伤的预防和治疗指南》（2008版）进行损伤分型及损伤部位的确定。对于术中即时发现的损伤,应及时中转开腹手术,并应邀请有丰富经验的肝胆外科医师进行处理。术后因胆漏或梗阻性黄疸而确诊,处理时间与远期效果关系密切。术后胆漏者,若引流通畅,影像学检查腹腔内无胆汁潴留,应观察治疗。胆漏3个月未能愈合或后期引起胆管瘢痕狭窄者,不适合内镜或介入治疗时,应行胆管修复手术。胆汁性腹膜炎,原则上应行胆管及腹腔引流,3个月后,再考虑行胆管修复治疗。梗阻性黄疸待胆管扩张后再行修复手术。后期胆管损伤的处理,根据胆管损伤的部位和类型,应选择适宜的治疗方法,包括微创内镜和介入治疗。加强专业技能的培训和督导是减少医源性胆管损伤的关键。     

腹腔镜胆囊切除术后胆瘘4例原因分析与防治

目的探讨腹腔镜胆囊切除术中胆瘘的原因、诊断及预防处理。方法回顾分析我院自2006年10月至2009年3月280例腹腔镜胆囊切除术中发生的4例胆瘘患者的临床资料,1例为胆总管损伤,1例为迷走胆管损伤,2例为胆囊管残端瘘。结果4例胆瘘患者均治愈,无任何并发症产生。结论尽早诊断、及时有效减压引流对腹腔镜胆囊切除术术中合并胆瘘的成功治疗有重要作用。     

Study of Relationship Between the Blood Supply of the Extrahepatic Bile Duct and Duct Supply Branches from Gastroduodenal Artery on Imaging and Anatomy

Background:Liver transplantation has become the treatment of choice for patients with end-stage acute or chronic hepatic disease.Bile duct complications are common events after liver transplantation.Th...     

腹腔镜胆囊切除的规范手术方式对预防胆管损伤的临床意义

目的探讨腹腔镜胆囊切除规范手术方式对预防胆道损伤发生的临床价值.方法通过设计腹腔镜胆囊切除手术流程规范并实施于所有手术病例中,完成手术760例.结果所有患者无肝外胆管损伤.结论实施腹腔镜胆囊切除手术流程规范,严谨合理,是降低肝外胆管损伤发生率的重要措施之一.     

腹腔镜胆囊切除术并发症处理与预防

目的:探讨腹腔镜胆囊切除术并发症发生的原因、处理及预防方法。方法:对725例腹腔镜胆囊切除术中11例并发症临床资料的回顾性分析。结果:胆管损伤1例,术中出血3例,术后胆漏1例,胃肠道损伤1例,穿刺切口感染1例,皮下气肿3例,残余结石1例。结论:严格掌握手术指征,合理的手术技巧,规范的操作,熟悉胆囊管和血管的解剖及变异,及时果断的中转开腹等,可以有效的减少腹腔镜胆囊切除术并发症的发生。     

腹腔镜胆囊切除术中肝外胆管损伤的因素分析及对策

目的减少或防止腹腔镜胆囊切除术中肝外胆管损伤的发生率．对术中已发生的肝外胆管损伤能及时、正确地进行补救处理,以尽可能减少术后并发症的发生．方法回顾分析本组自1991年9月至2013年7月腹腔镜胆囊切除术8700余例,其中发生肝外胆管损伤12例的临床资料,发生率为0．13％．术中采用正确的处理方法分辨各管系的关系,尽可能地避免损伤．如已经发生损伤,需及时发现,认真分析肝外胆管损伤的类型及部位,进行妥当的手术修补或端端吻合,放置引流．结果本组12例全部治愈出院,5～10a随访恢复良好．结论腹腔镜胆囊切除手术中需要谨慎处理各管系的关系,不要盲目离断、灼烧管道,以尽可能避免损伤肝外胆管;对已发生的肝外胆管损伤需及时发现;术中得到正确的手术处理,可减少或避免术后并发症的发生．     

Childhood circumcision in Northern Ireland: a barometer of the current practice of general paediatric surgery

Purpose:

Studies undertaken in England and Scotland have identified a decrease in the number of circumcision operations being performed during childhood. The aims of this study were two-fold. Firstly, to determine the trend in circumcision operations performed in boys in Northern Ireland over a ten year period. Secondly, to compare the number of operations performed by paediatric surgeons with the number performed by general surgeons over the same period.

Method:

Data were collected from the Northern Ireland Department of Health and Social Services and Public Safety. A retrospective analysis was conducted of the number of circumcisions performed in boys aged between 0 and 13 years for the year beginning 1^st September 1991 to the 1^st of September 1992 and for the year beginning 1^st September 2001 until the 1^st of September 2002.

Results:

769 circumcisions were performed in the year 1991 to 1992 compared with 264 in the year 2001 to 2002, representing a 66% decrease. In the ten year study period, the number of circumcisions performed by general surgeons fell by 71% whilst specialist paediatric surgeons performed 56% less.

Conclusions:

The decrease in rates of circumcision in boys aged 0 to 13 years in Northern Ireland is consistent with trends in the remainder of the United Kingdom. The results also suggest a greater decrease in the proportion of circumcisions being performed by general surgeons in district general hospitals compared to those performed by paediatric surgeons.     

The effectiveness of a new generation of computerized drug alerts in reducing the risk of injury from drug side effects: a cluster randomized trial

Context

Computerized drug alerts for psychotropic drugs are expected to reduce fall-related injuries in older adults. However, physicians over-ride most alerts because they believe the benefit of the drugs exceeds the risk.

Objective

To determine whether computerized prescribing decision support with patient-specific risk estimates would increase physician response to psychotropic drug alerts and reduce injury risk in older people.

Design

Cluster randomized controlled trial of 81 family physicians and 5628 of their patients aged 65 and older who were prescribed psychotropic medication.

Intervention

Intervention physicians received information about patient-specific risk of injury computed at the time of each visit using statistical models of non-modifiable risk factors and psychotropic drug doses. Risk thermometers presented changes in absolute and relative risk with each change in drug treatment. Control physicians received commercial drug alerts.

Main outcome measures

Injury risk at the end of follow-up based on psychotropic drug doses and non-modifiable risk factors. Electronic health records and provincial insurance administrative data were used to measure outcomes.

Results

Mean patient age was 75.2 years. Baseline risk of injury was 3.94 per 100 patients per year. Intermediate-acting benzodiazepines (56.2%) were the most common psychotropic drug. Intervention physicians reviewed therapy in 83.3% of visits and modified therapy in 24.6%. The intervention reduced the risk of injury by 1.7 injuries per 1000 patients (95% CI 0.2/1000 to 3.2/1000; p=0.02). The effect of the intervention was greater for patients with higher baseline risks of injury (p<0.03).

Conclusion

Patient-specific risk estimates provide an effective method of reducing the risk of injury for high-risk older people.

Trial registration number

clinicaltrials.gov Identifier: NCT00818285.     

腹腔镜胆囊切除术围手术期的护理

目的探讨腹腔镜胆囊切除术的围手术期护理方法。方法回顾性分析2007年1月-2009年8月,738例胆囊结石、胆囊息肉者施行腹腔镜胆囊切除术的临床资料,总结围手术期的护理措施和并发症的观察与护理。术前对患者进行全面的身体评估、做好健康指导及心理护理。术后患者回病房后给予常规护理,严密监测循环、呼吸系统,密切观察腹部体征及全身情况。同时给予饮食、活动和出院指导,预防并发症。结果 738例腹腔镜胆囊切除术,术中因1例胆总管损伤中转行横断胆管端-端吻合、T管引流术;5例出血、经腹腔镜探查胆囊周围严重粘连而中转开腹行胆囊切除术,其余手术顺利完成。术后发现2例胆总管损伤,9例腹腔出血,3例戳洞处出血,5例胆漏,21例肩部疼痛,经及时治疗与护理,全组病例均痊愈出院。结论虽然经腹腔镜胆囊切除术创伤小、痛苦少、术后恢复快,但也存在着一定的风险和并发症。只有科学、周密地做好围术期的治疗和护理,才是手术成功的重要保证。     

Management of Vascular Injuries in a Forward Hospital

Background

Management of vascular injuries poses a challenging problem under warlike conditions. Several authorities recommend limb revascularisation only within first 6-8 hours, as the outcome after delayed revascularisation is poor.

Methods

A retrospective analysis of 61 consecutive patients with vascular injury in a forward hospital over a 25- month period was carried out.

Results

Vascular injuries constituted 3.1% of all injuries. The mean injury to treatment delay (lag time) was 11 hours, and 10 patients received treatment after 12 hours. The overall amputation rate was 15%, but only 6.5% for those revascularised within 12 hours and 44% for those undergoing surgery after 12 hours (Chi-square 4.59, p < 0.05). Presence of associated fractures was associated with an adverse outcome (Chi-square 4.24, p < 0.05), as was ligation in comparison to revascularisation (Chi-square 7.86, p < 0.005). Popliteal injuries were associated with a high amputation rate.

Conclusions

Failure to revascularise (ligation of artery), presence of associated fracture, and restoration of circulation beyond 12 hours are associated with a high amputation rate.Key Words: Vascular injuries, trauma, amputation     

Major laparoscopic surgery under regional anesthesia: A prospective feasibility study

Background

Laparoscopic surgeries have attained the status of a gold standard for most of the abdominal pathology; we therefore performed this study to assess feasibility and safety of major laparoscopic surgeries like laparoscopic cholecystectomy (LC) and laparoscopic assisted vaginal hysterectomy (LAVH)/total laparoscopic hysterectomy (TLH) under regional anesthesia that is combined spinal epidural anesthesia (CSE) with normal pressure pneumoperitoneum using intrathecal fentanyl with bupivacain.

Methods

In a zonal government hospital, 50 patients were selected prospectively for LC and LAVH/TLH, under normal pressure (12 mmHg) pneumoperitoneum and under CSE over a span of fifteen months. Injection bupivacaine (0.5%) and 20 μg of fentanyl were used for spinal anesthesia. Plain bupivacaine (0.5%) was used for epidural anesthesia.

Results

We successfully performed the operations in 48 patients without major complications. CSE was converted to general anesthesia in two patients due to distressing shoulder tip pain. Age varied between 25 and 70 years. Duration of operation time (skin to skin) was between 50 and 170 min. Five patients had urinary retention and one developed localized pruritis. There was no incidence of respiratory depression, aspiration or headache.

Conclusion

Laparoscopic surgeries with normal pressure CO₂ pneumoperitoneum are feasible and safe under CSE. Incidence of postoperative shoulder pain was minimal due to use of intrathecal fentanyl and complications were less and easily manageable.