针刺减压与吸引器减压在急性胆囊炎腹腔镜胆囊切除术中的应用

目的:探讨急性胆囊炎行腹腔镜胆囊切除术中应用针刺减压与吸引器减压的安全性及优劣。方法:回顾分析2021年1月1日至2021年6月1日为101例急性胆囊炎患者行腹腔镜胆囊切除术的临床资料,其中50例采用针刺减压(针刺组),51例采用吸引器穿刺减压(吸引器组)。结果:101例患者均顺利完成腹腔镜胆囊切除术,无并发症发生。术后第1天、第3天,两组白细胞、中性粒细胞百分比、C反应蛋白差异无统计学意义,术中出血量、术后排气时间、术后住院时间、细菌培养阳性、总费用差异亦无统计学意义。吸引器组手术时间短于针刺组[(95.4±10.1)min vs.(114.0±3.0)min,P<0.05],差异有统计学意义。术后病理示急性胆囊炎或慢性胆囊炎急性发作(合并或不合并胆囊结石)。结论:在多种方法结合、仔细操作的前提下,急性胆囊炎行腹腔镜胆囊切除术是安全、有效的,吸引器减压较针刺减压效果更好。     

普通吸引器刮吸法行急性胆囊炎腹腔镜胆囊切除术

2006年6月～2011年12月,对106例急性胆囊炎行腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC),病程1 d～2周,其中62例病程>3 d。三孔法44例,四孔法62例。用腹腔镜普通吸引器边钝性分离胆囊颈管和胆囊床,边吸引保持术野清晰,超声刀处理胆囊动脉和止血,胆囊颈管结扎或缝合处理,38%(40/106)留置温氏孔腹腔引流管。顺利完成手术105例,1例因胆囊颈管损伤中转开腹。手术时间42～86 min,平均56 min;出血量45～150 ml,平均86 ml。术后胆漏4例,1例行鼻胆管引流1周痊愈,3例腹腔引流3～7 d痊愈。认为使用普通吸引器刮吸法可以较清晰地显露胆囊周围各层间的解剖关系,使腹腔镜下急性胆囊炎手术变得更安全和易于成功。     

刮吸法在急性胆囊炎腹腔镜胆囊切除术中的应用

目的总结刮吸法用于急性胆囊炎腹腔镜胆囊切除术中的经验。方法回顾159例采用刮吸法行腹腔镜胆囊切除术治疗急性胆囊炎患者的临床资料。结果159例顺利完成手术150例,中转开腹9例。平均手术时间60 min,平均出血量86.4 ml,术中置腹腔引流管52例,平均住院5 d。术后胆漏2例,经腹腔引流后康复。结论正确使用刮吸法可较清晰的显露胆囊周围各层间的解剖关系,使手术变得便捷和安全。     

急性胆囊炎胆囊颈管结石嵌顿的腹腔镜胆囊切除术

目的总结急诊腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)治疗急性胆囊炎胆囊颈管结石嵌顿的心得体会。方法回顾性分析急性胆囊炎胆囊颈管结石嵌顿51例的临床资料,手术采用四孔法和吸引器推吸钝性分离以及Hartmann袋或胆囊管切开取石法行腹腔镜胆囊切除术。结果 49例(96.1%)顺利完成LC,2例(3.9%)患者术中无法辨清胆囊三角的结构关系而及时中转开腹,无胆管损伤发生,切口感染3例(5.9%),51例均痊愈,术后平均4.5(2~10)d出院。结论急诊腹腔镜胆囊切除治疗急性胆囊炎胆囊颈管结石嵌顿是安全可行的,在胆囊三角解剖困难时,采用Hartmann袋或胆囊管切开取石后再行腹腔镜胆囊切除是预防胆管损伤的好方法。     

腹腔镜胆囊切除术治疗急性坏疽性胆囊炎36例

目的探讨应用腹腔镜胆囊切除术治疗急性坏疽性胆囊炎的手术技巧。方法回顾性分析2008年4月至2012年1月收治的36例急性坏疽性胆囊炎患者的临床资料,均行腹腔镜胆囊切除术（LC）。结果 36例均成功完成手术,其中2例中转开腹,术后无出血、胆瘘、胆总管损伤等并发症发生,术后住院3～7d,1例术后第7天（已出院）发生下肢深静脉血栓,经溶栓治疗痊愈。结论急性坏疽性胆囊炎为LC的相对适应证,术中联合应用吸引器、纱布压迫等方法,可以减少出血,保持术野清晰,容易辨认组织结构,减少和避免术中误伤和术后并发症的发生。     

腹腔镜下复杂胆囊切除术119例临床分析

目的探讨腹腔镜胆囊切除术在复杂情况下的处理。方法回顾性分析2013年7月~2016年7月119例腹腔镜下行复杂胆囊切除术患者的临床资料。其中,胆囊结石合并急性化脓性胆囊炎55例,坏疽性胆囊炎20例,胆囊穿孔12例,萎缩性胆囊炎27例,残余胆囊切除5例。35例有腹部手术史。术中采用"刮吸"、"推扒"的操作方法分别显露胆囊前、后三角;出血较多时使用干纱布填塞出血部位;遇到胆囊张力较高影响手术视野时先行胆囊减压。结果本组119例均顺利完成腹腔镜胆囊切除术,平均手术时间75(45~220)min。术后无明显出血,无胆漏发生,术后伤口疼痛予以对症处理后症状缓解。留置引流管的92例患者于术后1~3 d复查腹部B超后拔除引流管,术后第3~7 d出院,术后平均住院日4.2 d。术后随访1~3个月均无相关并发症发生。结论腹腔镜胆囊切除术可适用于复杂患者,合理熟练使用吸引器及干纱布可使手术过程简化。     

电凝吸引器钝性分离法在重症急性胆囊炎早期腹腔镜胆囊切除术中的应用

目的探讨电凝吸引器钝性分离法在重症急性胆囊炎早期腹腔镜胆囊切除术中的应用价值。方法对2008年3月～2009年7月56例诊断为重症急性胆囊炎患者在四孔法腹腔镜下应用电凝吸引器钝性分离法处理胆囊三角及从胆囊床上分离胆囊,记录出血量、手术时间、中转开腹率,术后腹腔积液、脓肿,肺部并发症及合并心脑疾患、糖尿病并发症,出院后随访有无胆囊床积液及胆道狭窄等并发症。结果手术时间35～110(62.7±16.7)min,出血量40～200(80.2±40.5)ml。无中转开腹手术及胆道损伤、胆漏,无明显腹腔积液、脓肿,无严重肺部并发症,围手术期未发生脑梗死或脑出血,5例冠状动脉支架置入者无心绞痛、心肌梗死及心律失常。术后随访2～3个月,无发热、腹痛及黄疸,影像学检查无胆囊窝血肿、积液以及胆道狭窄等并发症。结论电凝吸引器钝性分离法治疗重症急性胆囊炎安全有效,值得临床推广。     

腹腔镜胆囊切除术治疗急性胆囊炎：附272例报告

目的 目的探讨急性胆囊炎腹腔镜胆囊切除术(LC)的术式、术中处理,并发症的防治.方法 回顾性分析2003年3月-2007年4月间272例急性胆囊炎患者临床资料,采用腹腔镜完整胆囊切除术260例,胆囊大部切除术加残余胆囊黏膜电灼破坏术12例.结果 无中转开腹者,无死亡、胆道损伤、大出血等严重并发症.结论 急性胆囊炎行腹腔镜胆囊切除术(LC)是安全、有效的.其出血少、创伤小、恢复快.     

急性胆囊炎腹腔镜切除术式选择

目的 :探讨急性胆囊炎行腹腔镜胆囊切除术的安全性。方法 :腹腔镜对急性胆囊炎的治疗分别选择 :胆囊大部分切除、胆囊前壁切除、胆囊完整切除三种术式。结果 :顺利完成腹腔镜胆囊切除 2 32例 ,中转手术 4例。全组无死亡病例 ,无胆道损伤、大出血等严重并发症。结论 :随着腹腔镜胆囊切除术经验积累和器械完善 ,急性化脓、坏死性胆囊炎甚至胆囊穿孔已不再是腹腔镜胆囊切除的禁忌证 ,均可在急性炎症期完成腹腔镜胆囊切除术。     

腹腔镜对老年急性结石性胆囊炎治疗的可行性

目的探讨腹腔镜下采取不同术式对老年急性结石性胆囊炎治疗的可行性。方法 2001-06～2009-06对106例60岁以上急性结石性胆囊炎腹腔镜治疗进行回顾分析。结果其中90例行常规腹腔镜胆囊切除术(LC),10例在腹腔镜下行胆囊造瘘术,6例行胆囊大部分切除术。中转开腹3例,无死亡,术后无严重并发症发生,均痊愈出院。结论选择LC治疗老年急性结石性胆囊炎是可行的。     

急性坏疽性胆囊炎腹腔镜治疗体会（附20例报告）

目的探讨腹腔镜治疗急性坏疽性胆囊炎的手术技巧性。方法回顾性分析我院自2006年4月至2007年7月LC治疗急性坏疽性胆囊炎20例临床资料。结果本组无一例中转开腹手术。1例由于胆囊壁已大部分坏疽、无法完整切除胆囊故行胆囊大部分切除，胆囊床电凝烧灼，术后无并发症发生，术后住院时间（除胆总管结石病例）3-5d。结论在急性坏疽性胆囊炎行腹腔镜胆囊切除时，联合使用超声刀、吸引器等方法。可减少出血，保持解剖清晰，提高安全、降低中转开腹率，值得进一步推广和应用。     

"Acute cholecystitis"--laparoscopic cholecystectomy is often possible. Results of a multicenter study by the East German Study Group for Performance Assessment and Quality Assurance in Surgery

With the introduction of laparoscopic cholecystectomy (LCE) the method became very fast successful in clinical practice. To describe the actual situation we initiated in 1994/95 a clinical multicenter study with the name CESAQ. 29 hospitals participated in the study. 4,675 cholecystectomies were performed, a total number of 2,960 patients were operated upon with the laparoscopic and 1,468 with the conventional technique. Furthermore, conversion to open cholecystectomy was necessary in 247 cases. One part of the study focused on the results achieved for patients with acute cholecystitis. 9.4% of the laparoscopic but 37.3% of the conventional cholecystectomies were performed due to acute cholecystitis. We differentiated a simple (adhesions to gallbladder, hydrops) and complicated form (empyema, gangrenous gallbladder) of acute cholecystitis. Treating acute cases the incidence of intraoperative (simple 8.3%, complicated 12.1%) and specific postoperative complications (simple 9.2%, complicated 6.9%) was higher compared to elective procedures (intraoperative 4.6%, specific postoperative 3.7%). This is well known from the experience of open surgery. Nevertheless there were lower general complication rates (simple 5.5%, complicated 5.2%) and no mortality in acute cholecystitis when LCE was performed. Considering an early conversion to open cholecystectomy in cases of severe acute cholecystitis the indication for LCE can be made generously. Great surgical experience in LCE is a requirement for the laparoscopic management of acute cholecystitis.     

急性坏疽性胆囊炎的“冷分离”腹腔镜胆囊切除术

目的探讨急性坏疽性胆囊炎时"冷分离"腹腔镜胆囊切除术的可行性以及手术技巧。方法回顾性分析河南科技大学第一附属医院普外科41例急性坏疽性胆囊炎行腹腔镜胆囊切除术的临床资料。术中采用分离钳剥离、配合吸引器刮吸的"冷分离"技术切除胆囊。结果 39例完成腹腔镜胆囊切除术,2例中转开腹手术,手术中转率为4.9%。手术时间为(70.37±13.35)min,术中无肝胆管损伤,术后无胆囊床渗血或胆漏发生。术后并发切口感染2例,切口血清肿1例,下肢浅静脉血栓形成1例,右下肺感染1例,均治愈出院。本组前12例平均手术时间为(86.67±11.69)min;后29例平均手术时间为(63.55±6.23)min,两者比较,差异有统计学意义(P0.01)。结论急性坏疽性胆囊炎行"冷分离"腹腔镜胆囊切除术安全可行,分离钳和吸引器相结合的"冷分离"技术是手术成功的有效方法。     

Laparoscopic cholecystectomy in acute cholecystitis

The authors retrospective analyze the role of golden standard laparoscopic cholecystectomy for the treatment of acute cholecystitis. They make a comparison between the results of 50 early cholecystectomy and 44 "a froid" cholecystectomy (operation was postponed until 6 weeks after acute cholecystitis had healed). From January 1997 to December 1998 536 laparoscopic cholecystectomies were performed. In 491 cases (91.6%) laparoscopic, and in 45 cases (8.4%) traditional (opening) method was indicated. Converted cholecystectomies were in 36 cases (7.3%). Agreeing to the literature they can determine the optimal timing of the operation in 72 hours from the onset of acute cholecystitis [2, 4]. In this group (first group) there were 50 cases, with 14 conversions (28%). In the second group (postponed, so called "a froid" phase) there were 44 patients. From this group was the intraoperative diagnosis serious acute-subacute cholecystitis in 24 cases (54.54%) causing complicated laparoscopic cholecystectomy and resulting in 11 conversions (11/44: 25%). The causes of the higher rate of conversion were the grave inflammation and slow dissection of central formation. There were no serious complication and mortality in both groups. It was diagnosed bile leak (two cases) which ceased spontaneously, one haematoma in abdominal layers, and one trocar's hernia. The authors have recommended the laparoscopic cholecystectomy for early diagnose acute cholecystitis in order to prevent the complications and reduce the sick-leave. Supporting their viewpoint the most important clinical end economical facts are: the recurrence of inflammation forced urgent surgery and caused more complication in the course of "a froid" phase there were scrutable anatomical situation the patients recovered in a shorter time.     

腹腔镜胆囊切除联合阑尾切除术30例临床经验与分析

目的 探讨急、慢诊施行腹腔镜胆囊(Laparoscopic cholecystectomy,LC)联合阑尾切除术(Laparoscopic appendectomy,LA)的操作要点和临床价值.方法 回顾性分析了我院2006年9月至2010年2月对30例患者施行腹腔镜胆囊联合阑尾切除术.其中,急性胆囊炎合并慢性阑尾炎1...     

急性结石性胆囊炎行腹腔镜逆行次全胆囊切除术的疗效观察

目的:探讨为急性结石性胆囊炎患者行腹腔镜逆行次全胆囊切除术的临床疗效。方法:回顾分析97例急性结石性胆囊炎患者的临床资料,其中48例行腹腔镜逆行次全胆囊切除术(观察组),49例行腹腔镜逆行胆囊切除术(对照组)。结果:两组均有1例中转开腹。观察组手术时间缩短,术中出血量减少,两组相比差异有统计学意义(P<0.05);术后第1天体温、术后并发症发生率及住院时间两组差异无统计学意义(P>0.05)。结论:腹腔镜逆行次全胆囊切除术治疗慢性结石性胆囊炎疗效满意,与腹腔镜逆行胆囊切除术相比,操作更简单,手术时间更短。     

Laparoscopic tube cholecystostomy: still useful in the management of complicated acute cholecystitis

The preferred treatment for acute cholecystitis is laparoscopic cholecystectomy. Conversion to open operation may be necessary in cases where the anatomy is unclear or complications are encountered. Laparoscopic tube cholecystostomy remains an alternative to open surgery in cases where the gallbladder is judged too inflamed to allow for laparoscopic removal and in cases where the patient is too sick to tolerate a more extensive procedure. It also provides access for diagnostic cholangiography. We report three patients with acute cholecystitis who underwent laparoscopic cholecystostomy and interval laparoscopic cholecystectomy without complications. Laparoscopic tube cholecystostomy is safe and remains a useful option in select patients with complicated acute cholecystitis.     

Factors associated with successful laparoscopic cholecystectomy for acute cholecystitis.

OBJECTIVE: This article determined which preoperative data correlated with successful completion of a laparoscopic cholecystectomy in patients with acute cholecystitis. SUMMARY BACKGROUND DATA: Although laparoscopic cholecystectomy is the procedure of choice in chronic cholecystitis, its use in acute cholecystitis may be associated with higher costs and complication rates. It is not known which patients with acute cholecystitis are likely to require conversion to open cholecystectomy based on preoperative data or if a cooling-off period with medical therapy can diminish inflammation and increase the chance of successful laparoscopic cholecystectomy. METHODS: All laparoscopic cholecystectomies done by the authors between 10/90 and 2/92 were reviewed. Data on cases of acute cholecystitis were prospectively collected on standardized data forms. RESULTS: Twenty of 281 laparoscopic cholecystectomies were done for acute cholecystitis; 7/20 patients with acute cholecystitis required conversion to open cholecystectomy compared with 6/281 patients undergoing elective operation for chronic cholecystitis. In patients with acute cholecystitis the interval from admission to cholecystectomy in the successful cases was 0.6 days vs. 5 days in the cases requiring conversion to open cholecystectomy (p = .01). Cases requiring conversion to open cholecystectomy also had higher WBC (14.0 vs. 9.0, p < .05), alkaline phosphatase (206 vs. 81, p < .02, and APACHE II scores (10.6 vs. 5.1, p < .05). Ultrasonographic findings such as gallbladder distention, wall thickness, and pericholecystic fluid did not correlate with the success of laparoscopic cholecystectomy. Patients converted from laparoscopic to open cholecystectomy required more operating room time (120 min vs. 87 min, p < .01) and more postop hospital days (6 vs. 2, p < .001). CONCLUSIONS: Laparoscopic cholecystectomy for acute cholecystitis should be done immediately after the diagnosis is established because delaying surgery allows inflammation to become more intense, thus increasing the technical difficulty of laparoscopic cholecystectomy.     

Surgical treatment of patients with acute cholecystitis: Tokyo Guidelines

Cholecystectomy has been widely performed in the treatment of acute cholecystitis, and laparoscopic cholecystectomy has been increasingly adopted as the method of surgery over the past 15 years. Despite the success of laparoscopic cholecystectomy as an elective treatment for symptomatic gallstones, acute cholecystitis was initially considered a contraindication for laparoscopic cholecystectomy. The reasons for it being considered a contraindication were the technical difficulty of performing it in acute cholecystitis and the development of complications, including bile duct injury, bowel injury, and hepatic injury. However, laparoscopic cholecystectomy is now accepted as being safe for acute cholecystitis, when surgeons who are expert at the laparoscopic technique perform it. Laparoscopic cholecystectomy has been found to be superior to open cholecystectomy as a treatment for acute cholecystitis because of a lower incidence of complications, shorter length of postoperative hospital stay, quicker recuperation, and earlier return to work. However, laparoscopic cholecystectomy for acute cholecystitis has not become routine, because the timing and approach to the surgical management in patients with acute cholecystitis is still a matter of controversy. These Guidelines describe the timing of and the optimal surgical treatment of acute cholecystitis in a question-and-answer format.