不同气腹压对老年患者腹腔镜胆囊切除术后肝功能的影响

目的探讨不同气腹压对老年患者腹腔镜胆囊切除术(LC)后肝功能的影响及其可能机制。方法选择60岁以上老年患者行LC76例,根据术中CO2气腹压水平将患者分为3组,即低气腹压组(LP组,n=20)腹内压(IAP)维持在1.3kPa水平、标准气腹压组(SP组,n=33)IAP维持在1.6kPa水平和高气腹压组(HP组,n=23)IAP维持在2.0kPa水平。其中SP组根据术中气腹维持时间再细分为两个亚组,即A亚组(时间>50min),B亚组(时间≤50min)。各组患者分别于术前、术后1d及术后4d抽取静脉血测定血清ALT、AST含量并进行对比研究。结果SP组和HP组的血清ALT、AST水平均在术后1d明显升高(P<0.01),其中HP组升高较SP组明显(P<0.01),而LP组升高不明显(P>0.05)。SP组在术后4d血清ALT、AST基本恢复至正常水平,而HP组虽有下降,但多数患者仍高于正常水平。SP组中的A亚组术后1d血清ALT、AST升高水平明显高于B亚组(P<0.01)。结论腹腔镜胆囊切除术中建立的CO2气腹可能引起老年患者术后一过性肝功能异常,且与CO2气腹压的高低和维持时间有关。     

心功能Ⅱ级患者行低气腹压腹腔镜胆囊切除术18例临床分析

目的 探讨心功能Ⅱ级患者在低气腹压下行腹腔镜胆囊切除术的可能性。方法总结我院2003年7月至2004年7月间收治的18例心功能Ⅱ级患者行低气腹压腹腔镜胆囊切除术的临床资料。结果18例心功能Ⅱ级患者中17例完成腹腔镜胆囊切除，1例中转开腹。结论心功能Ⅱ级患者行低气腹压腹腔镜胆囊切除术是可行的。     

低气腹腹腔镜胆囊切除345例

我们应用腹腔镜技术治疗老年胆囊疾病患者620例,其中345例患者施行低气腹手术,效果满意,现报道如下。1.资料和方法:(1)临床资料:1995年4月～1997年11月共治疗老年胆囊疾病老年患者620例。随机分为2组:常规气腹手术组275例,年龄60～74岁;慢性胆囊炎伴结石209例,慢性胆囊炎44例,胆囊息肉21例。低气腹手术组345例,年龄63～71岁;慢性胆囊炎伴结石267例,慢性胆囊炎54例,胆囊息肉25例。常规气腹组和低气腹组患者主要并存疾病分别为高血压(94、76例)、冠心病(73、84例)、肺气肿(48、62例),糖尿病(64、58例)、慢性胰腺炎(11、18例)。2组患者在年龄、…     

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。     

不同气腹压力下腹腔镜胆囊切除术气腹并发症的比较研究

目的探讨腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)气腹并发症的防治. 方法回顾分析1993年10月至2003年1月1 100例LC的临床资料,2001年9月前入院的980例为A组,气腹压力设定14 mm Hg,2001年9月以后的120例为B组,气腹压力设定10 mm Hg. 结果 B组无明显高碳酸血症发生,而A组有2例发生;B组肩部疼痛发生率19.2%(23/120)明显低于A组43.9%(430/980)(χ2=26.951,P=0.000).B组恶心呕吐发生率25.8%(31/120)明显低于A组61.2%(600/980)(χ2=54.750,P=0.000). 结论高碳酸血症、肩部疼痛及恶心、呕吐等气腹并发症可通过术中注意调节通气量,降低气腹压力等措施防治.     

腹腔镜胆囊切除术后气腹存留时限的X线观察

目的观察腹腔镜胆囊切除术后气腹存留时限. 方法对我院2002年4月～2002年12月69例腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)术后进行连续胸部 X线平片观察膈下游离气体. 结果 LC术后气腹存留时限为(1.8±1.1)d,6 d内完全吸收.lg气腹存留时限与术后24 h膈下残气量呈正相关(r=0.616,P=0.000),与气腹时间呈负相关(r=-0.228,P=0.014),与年龄、体重、身高、手术时间及所用气体量无相关性. 结论术毕尽量将腹腔内CO2气体排净可缩短术后气腹吸收时间.     

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。     

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。     

腹腔镜胆囊切除术中气腹压和气腹持续时间对病人内脏灌注的影响

目的探讨腹腔镜胆囊切除术中气腹压及气腹持续时间对病人内脏灌注的影响。方法 50例ASA Ⅰ或Ⅱ级、年龄<65岁的择期腹腔镜下单纯胆囊切除术病人,随机分为气腹压12 mm Hg 组(LC1)和气腹压15 mm Hg组(LC2),每组25例。全麻诱导气管插管后行机械通气,1．5％-2％异氟醚吸入,间断给予芬太尼、维库溴铵维持麻醉。术中维持PETCO2约34 mm Hg。于麻醉诱导前即刻 (T1)、气管插管后30min(T2)、气腹30min(T3)、60min(T4)、放气后30min(T5)、入麻醉恢复室后1 h (T6)、2 h(T7)、3 h(T8)监测并记录循环指标、血气分析及胃粘膜二氧化碳分压(PgCO2)。根据 Henderson-Hasselbalch公式计算胃粘膜pH(pHi)和胃粘膜与动脉血二氧化碳分压梯度(PCO2gap)。结果与T1比较,两组T6-8时PgCO2升高,pHi下降(P<0．01),PCO2gap差异无统计学意义。与T2比较, LC1组T3-5时PgCO2、pHi、PCO2gap差异无统计学意义。与T2、T3及LC1组比较,LC2组T4时PgCO2、 PCO2gap升高,pHi降低(P<0．01),T5上述参数恢复至气腹前水平。结论腹腔镜胆囊切除术中腹内压15 mm Hg时,随气腹时间的延长(60 min)可引起短时的内脏低灌注。腹腔镜胆囊切除术中腹内压维持在12mmHg较为适宜。     

腹腔粘连患者腹腔镜胆囊切除术闭合法建立气腹

目的 探讨腹腔粘连患者腹腔镜胆囊切除术（LC）闭合法建立气腹的方法。方法 回顾性分析1991年9月－1999年9月6600例LC中1046例腹腔粘连患者闭合法建立气腹的经过。建立气腹困难分为真性建立气腹困难及假性建立气腹困难2种。由于气腹针穿入腹腔脏器或腹腔广泛粘连导致气体弥散困难引起的建立气腹困难称真性建立气腹困难,需中转开腹手术;由于气腹针位置错误如位于腹膜外脂肪层、肝园韧带或大网膜内引起的建立气腹困难称假性建立气腹困难,调整气腹针位置,均能满意建立气腹。结果 1046例中1028例成功建立气腹。5例因真性建立气腹困难,13例因假性建立气腹困难而中转开腹。本组腹腔粘连患者闭合法建立气腹成功率为98．3％。结论 腹腔粘连患者闭合法建立气腹是安全可行的。缺乏自信、经验不足、误把假性建立气腹困难当作真性建立气腹困难是腹腔粘连患者闭合法建立气腹失败的主要原因。     

Prospective randomized trial on low-pressure versus standard-pressure pneumoperitoneum in outpatient laparoscopic cholecystectomy

Inpatient low-pressure pneumoperitoneum laparoscopic cholecystectomy (LPLC) has been shown to have less postoperative pain (especially shoulder-tip pain). No report so far has documented the use of lower-pressure pneumoperitoneum in outpatient laparoscopic cholecystectomy (LC). A prospective randomized trial was conducted in Tung Wah Hospital, Day Surgery Centre from January 2004 to December 2004. A total of 40 patients were recruited and 20 of whom were allocated to each arm. Outcome measures included operation time, treatment-related morbidity, mortality, postoperative pain (eg, shoulder-tip pain), consumption of analgesics, and level of satisfaction. All patients in both groups could be discharged on the same day. Patients' demographics and operation time were comparable in both groups. There were no treatment-related morbidity and mortality, nor was there any significant difference in postoperative pain. Less shoulder-tip pain was observed in the LPLC group though without significant difference (5% vs. 20%; P=0.151). Three patients in the LPLC group needed higher insufflation pressure (12 mm Hg) because of inadequate exposure and adhesions, and the operations were successful in all of them. Otherwise, no conversion to open procedure was noted in both groups. The consumption of analgesics was minimal and a high level of satisfaction was achieved in both groups of patients. The present study demonstrated no difference in LPLC and standard-pressure pneumoperitoneum laparoscopic cholecystectomy in the outcomes of outpatient LC. Routine use of lower-pressure pneumoperitoneum in outpatient LC would not be recommended unless in selected straightforward cases.     

Routine low-pressure pneumoperitoneum during laparoscopic cholecystectomy

BACKGROUND: Pneumoperitoneum at 15 mmHg results in dangerous hemodynamic disturbances in some patients. The use of low-pressure insufflation may make laparoscopic surgery safer. METHODS: Data were collected prospectively from a consecutive series of patients who had undergone an elective laparoscopic cholecystectomy (LC) by the same surgeon, during the years 1993-94 (group 1, 77 patients) and 1996 (group 2, 50 patients). The groups were similar with respect to age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) grade, existence of abdominal scars due to previous surgery, and severity of gallbladder disease. Patients underwent LC with a mean intraabdominal pressure of 10.56 mmHg in group 1 and 7 mmHg in group 2, respectively. RESULTS: The mean operative time was 75 min and 78 min in groups 1 and 2, respectively (NS). Insertion of an additional cannula was required more frequently (24% versus 14%; NS) in group 2. There were no conversions in either group. The morbidity rate and the postoperative hospital stay were similar for both groups. CONCLUSIONS: LC can be performed routinely at low intraabdominal pressure, which may contribute to the safety and comfort of the procedure.     

A prospective randomized trial on comparison of low-pressure (LP) and standard-pressure (SP) pneumoperitoneum for laparoscopic cholecystectomy

Aim: This study aimed to investigate the advantages and disadvantages of LP (7 mmHg) in comparison to SP (12 mm Hg) pneumoperitoneum in a prospective randomized clinical trial. Materials and Methods: 148 consecutive patients qualified for laparoscopic cholecystectomy (LC) due to uncomplicated symptomatic gallstones were randomized to either SPLC or LPLC. All the procedures were performed by the same experienced team of surgeons. The statistical analysis included sex, mean age, body mass index, ASA grade, operative time, complication rate, conversion rate, postoperative pain assessed by the Visual Analogue Scale of Pain (VAS) including the incidence of shoulder-tip pain, postoperative hospital stay, recovery time, and the quality of life (QOL) within 7 days following the operation. p <0.05 was considered as indicative of significance. Results: Neither conversion to an open procedure nor major complications occurred in either group. The operative time was similar in both groups (LP 55.7 ± 8.6 min vs SP 51.9 ± 8.3 min). The mean postoperative pain score was 6.18 ± 3.48 lower after LP than SPLC and the difference amounted to 22.2% (p <0.005). The incidence of shoulder-tip pain was 2.1 times lower after LP than SPLC (p <0.05). QOL within 7 days following the operation was remarkably better after LPLC than after SPLC (p <0.01). Conclusions: LP pneumoperitoneum is superior to SP pneumoperitoneum in terms of lower postoperative pain, a lower incidence of shoulder-tip pain, and a better QOL within 5 days following the operation. LP should be used for LC in cases of uncomplicated symptomatic gallstones as a recommended procedure as long as an adequate exposure is obtained with this technique.     

Low-pressure versus standard-pressure pneumoperitoneum for laparoscopic cholecystectomy: a systematic review and meta-analysis

Background

The feasibility and safety of low-pressure pneumoperitoneum in laparoscopic cholecystectomy remain unclear.

Methods

A meta-analysis of randomized controlled trials comparing low-pressure with standard-pressure pneumoperitoneum was performed.

Results

A total of 1,263 patients were included. Low-pressure pneumoperitoneum was associated with significantly decreased postoperative pain. The requirement for increased pressure was significantly greater in the low-pressure group (risk ratio = 6.16; P < .001). Operative time was similar, with only a slight statistical significance (weighted mean difference = 2.07; P < .001). Length of hospital stay was shorter in the low-pressure group (weighted mean difference = −.27; P = .01). No significant differences were found in surgical complications or conversion to open surgery.

Conclusions

Low-pressure pneumoperitoneum is feasible and safe and results in reduced postoperative pain and near-equal operative time compared with standard-pressure pneumoperitoneum. More studies are required to investigate the potential benefits of the reduced length of hospital stay.     

低压辅助悬吊式腹腔镜胆囊切除术在肥胖患者中的应用

目的：探讨低压辅助悬吊式腹腔镜胆囊切除术在肥胖患者中的应用。方法：回顾分析2008年8月至2009年8月为近期未发作的胆囊结石、急性胆囊炎或慢性胆囊炎急性发作不超过72h,BMI指数〉25的136例患者行腹腔镜手术的临床资料,将其随机分为CO2气腹组（n=60,对照组）和低压辅助组（n=76,实验组）。结果：136例均顺利完成手术,成功率100%,无血管损伤、脏器穿孔、胆道损伤、胆漏等并发症发生及中转开腹。手术时间两组差异无统计学意义。结论：低压辅助悬吊式腹腔镜胆囊切除术安全可行,效果与气腹腹腔镜胆囊切除术相同。     

The protocol of low-impact laparoscopic cholecystectomy: the combination of mini-laparoscopy and low-pressure pneumoperitoneum

Low-impact laparoscopic (LIL) cholecystectomy is an innovative surgical protocol that combines the use of mini-laparoscopic instruments (3-mm ports) under a low- and stable-pressure pneumoperitoneum (8 mmHg), with the aim of minimizing the surgical invasiveness and the risks related to CO₂ insufflation on the peritoneal environment. In day-surgery settings, LIL may contribute to increase the surgical success due to several potential benefits in terms of postoperative pain intensity and time to full recovery. In 14 consecutive patients requiring cholecystectomy for uncomplicated cholelithiasis, LIL was carried out uneventfully. No conversion, intra-operative or postoperative complications occurred. All patients were discharged the same day of surgery. Postoperative pain was well tolerated with no need of prolonged opioid therapy. Technical aspects and indications for LIL cholecystectomy are detailed.     

低压气腹腹腔镜技术在老年急性阑尾炎中的临床应用

【摘要】 目的 探讨低压气腹腹腔镜技术在治疗老年急性阑尾炎的临床疗效。方法〓回顾性分析2013年1月至2016年1月在我院住院治疗的104例老年急性阑尾炎,常规气腹腹腔镜技术治疗组52例,低压气腹腹腔镜技术治疗组52例,比较两组手术时间、术中出血量、术后并发症、住院时间,及对二氧化碳分压(PaCO₂)、N端脑钠肽(BNP)的影响。结果〓两组患者均顺利完成腹腔镜阑尾切除,无中转开腹。低压气腹组平均手术时间36.6±0.3 min与常规气腹组33.7±11.2 min相比无显著性差异(P=0.17);低压气腹组术中平均出血量40.1±5.3 mL较对常规气腹组38.5±4.3 mL增多,差异无统计学意义;低压气腹组住院时间3.2±1.2 d,较常规气腹组4.5±1.3 d缩短,差异具有统计学意义(P<0.01)。低压气腹组术后并发症2例,与对照组8例相比,差异具有统计学意义(P=0.046)。常规气腹组术后PaCO₂和BNP均较实验组显著升高,差异具有统计学意义(P<0.01)。结论〓低压气腹腔镜在治疗老年急性阑尾炎方面疗效确切,有利于术后快速康复及减少对心肺功能的影响,值得进行临床试用。     

Randomized comparison between low-pressure laparoscopic cholecystectomy and gasless laparoscopic cholecystectomy

Background: Laparoscopic cholecystectomy using low-pressure pneumoperitoneum (8 mmHg) minimizes adverse hemodynamic effects, reduces postoperative pain, and accelerates recovery. Similar claims are made for gasless laparoscopy using abdominal wall lifting. The aim of this study was to compare gasless laparoscopic cholecystectomy to low-pressure cholecystectomy with respect to postoperative pain and recovery. Methods: Thirty-six patients were randomized to low-pressure or gasless laparoscopic cholecystectomy using a subcutaneous lifting system (Laparotenser). Results: The characteristics of the patients were similar in the two groups. The procedure was completed in all patients in the low-pressure group, but two patients in the gasless group were converted to pneumoperitoneum. There were no significant differences in postoperative pain and analgesic consumption, but patients in the gasless group developed shoulder pain more frequently (50% vs 11%, p < 0.05). Gasless operation took longer to perform (95 vs 72.5 min, p= 0.01). Conclusions: Gasless and low-pressure laparoscopic cholecystectomy were similar with respect to postoperative pain and recovery. The gasless technique provided inferior exposure and the operation took longer, but the technique may still have value in high-risk patients with cardiorespiratory disease. Received: 10 August 1998/Accepted: 12 February 1999     

A comparative study of angiogenic and cytokine responses after laparoscopic cholecystectomy performed with standard- and low-pressure pneumoperitoneum

Background  Surgical procedures enhance production of pro- and anti-inflammatory cytokines and angiogenic factors that play a pivotal role in the immunological response to surgical trauma and take part in the pathogenesis of tumor growth and adhesions formation. The purpose of the study was to access the influence of low-pressure CO₂ pneumoperitoneum on the inflammatory and angiogenic responses during the postoperative period after laparoscopy. Methods  The study group consisted of 40 patients, operated on due to cholelithiasis using standard-pressure (n = 20) and low-pressure (n = 20) CO₂ pneumoperitoneum. Serum concentration of interleukin (IL)-6, IL-8, IL-10, vascular endothelial growth factor (VEGF)-A, and endostatin were measured before and at 6, 24, and 48 h after surgery with commercially available enzyme-linked immunosorbent assay (ELISA). Results  Concentrations of IL-6 increased significantly after the operations in both groups. No differences were observed between the groups in regards to IL-6, IL-8, and IL-10 levels. Concentrations of VEGF-A measured at 6 and 48 h were significantly lower in patients who underwent laparoscopies performed with low-pressure pneumoperitoneum. No significant variations were observed in endostatin serum concentration. Concentrations of the studied parameters were not influenced by duration of surgery or by age, gender, or body mass index (BMI) of the patients. Conclusions  The results obtained in our study do not show any significant differences between studied operative procedures with regards to systemic inflammatory response. Changes in the concentrations of VEGF-A and endostatin observed in the studied population may suggest this technique is more favorable with regards to angiogenesis process intensity, along with all its consequences and implications.     

免气腹与气腹腹腔镜胆囊切除术的对比研究

目的：探讨免气腹腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）与气腹LC的临床应用价值。方法：随机抽取60例胆囊疾病患者,分为免气腹LCⅠ组与气腹LC组各30例,同时选择合并慢性阻塞性肺病或冠心病的胆囊炎患者10例为免气腹LCⅡ组,进行临床观察和实验研究。结果：免气腹LC在术后镇痛药应用、术后体温、住院费用、并发症、血流动力学指标及免疫功能等均优于气腹LC。结论：（1）免气腹LC具有手术创伤小、术后患者痛苦轻、住院费用少等优点,优于气腹LC,术中出血量、术后应用抗生素时间两组差异无统计学意义;（2）免气腹LC较气腹LC在免疫功能方面更具优越性;（3）气腹改变血流动力学指标;（4）免气腹腹腔镜对因气腹禁忌而失去常规腹腔镜手术机会的患者具有重要的临床价值。