腹腔镜手术治疗老年急性坏疽性胆囊炎

目的 总结应用腹腔镜技术治疗老年急性坏疽性胆囊炎的临床效果和手术经验.方法 回顾性分析2008年1月至2012年11月应用腹腔镜技术治疗老年急性坏疽性胆囊炎15例的临床资料.结果 行腹腔镜胆囊切除术10例,胆囊部分切除术5例.手术均获得成功,无中转开腹,无严重心肺并发症发生.术后胆漏1例,7d后出院.结论 根据术中情况,胆囊减压,应用超声刀顺逆结合切除或大部分切除胆囊是安全的,腹腔镜手术是治疗老年急性坏疽性胆囊炎有效的方法.     

腹腔镜胆囊切除术治疗急性坏疽性结石性胆囊炎

目的探讨腹腔镜胆囊切除术治疗急性坏疽性结石性胆囊炎的手术适应证、手术技巧及并发症的防治。方法回顾分析2005年7月至2009年7月采取顺切、逆切或大部分切除等方法行腹腔镜胆囊切除术的500例急性坏疽性结石性胆囊炎患者的临床资料。结果合并胆囊胃瘘1例,同时行胃修补术;胆总管损伤4例,术中用5-0可吸收线行一期缝合,术后无胆漏、胆管狭窄发生。8例中转开腹。手术时间20～90min,平均35min;术中出血5～100ml,平均30ml。术中无肠管、血管损伤,术后无胆漏、出血发生,无其他严重并发症,全组无死亡病例。320例放置引流管,术后24～48h拔除。术后3～8d痊愈出院,平均住院时间5d。全组腹腔镜胆囊切除术成功率98.4%,中转开腹率1.6%。结论只要掌握恰当的适应证与手术时机,应用顺切、逆切或大部切除等方法,急性坏疽性结石性胆囊炎是可以安全成功施行腹腔镜胆囊切除术的。     

急性胆囊炎腹腔镜手术时中转开腹原因分析

目的探讨急性胆囊炎腹腔镜胆囊切除手术中转开腹的原因. 方法回顾分析32例急性炎症期行腹腔镜胆囊切除术的临床资料. 结果 32例中成功25例(78.1%), 中转开腹7例(21.9%).中转开腹原因主要是胆囊坏疽(4例)和不能清楚显露胆囊三角(3例). 结论对坏疽性胆囊炎和不能清晰解剖胆囊三角的急性胆囊炎应及时中转开腹手术.     

腹腔镜下切除急性坏疽性胆囊致胆管损伤的临床分析

目的探讨腹腔镜下切除急性坏疽性胆囊术中避免损伤胆管的可行性分析及手术技巧。方法回顾性分析湖北省中西医结合医院普通外科收治的168例急性坏疽性胆囊炎病人的临床资料。结果156例病人行腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC),10例病人行腹腔镜下胆囊大部分切除术。1例Mirizzi综合征病人术中出现胆总管损伤中转开腹行胆肠吻合术。1例病人术中误扎胆总管,再次手术行胆肠吻合术。结论急性坏疽性胆囊炎病人术前给予充分评估,术中掌握操作要点可有效避免胆管损伤等并发症。     

急性坏疽性胆囊炎69例的腹腔镜治疗

目的 探讨腹腔镜治疗急性坏疽性胆囊炎中转开腹的危险因素及影响预后的指标。方法 总结69例急性坏疽性胆囊炎腹腔镜手术的临床资料，包含术前临床指标和预后相关因素。计量资料采用x^-±s表示，行t检验；计数资料行χ^2检验。结果 腹腔镜手术成功完成45例，中转开腹24例；中转开腹的危险因素为年龄（χ^2=2．234，P=0．034）和合并心血管疾病（χ^2=4．983，P=0．027）；早期行腹腔镜手术和术中及时中转开腹的病例预后较好。结论 急性坏疽性胆囊炎应早行腹腔镜探查，若操作困难，应早期及时中转开腹手术；对于高龄和合并有心血管疾病的患者，应行开腹胆囊切除术。     

ERCP＋EST术后并发急性坏疽性胆囊炎的腹腔镜胆囊切除

目的探讨患者ERCP＋EST术后发生急性坏疽性胆囊炎（AGC）的腹腔镜胆囊切除体会。方法回顾性分析2001年7月至2009年7月开展的766例EST患者的临床病理资料,对16例AGC患者的腹腔镜胆囊切除手术进行回顾性分析。结果 16例患者EST术后同时合并或者并发AGC,发生率为2.1%,AGC的手术治疗为腹腔镜胆囊切除,其中3例中转开腹手术,术后发生并发症的风险相对较大,16例患者经过手术治疗和术后积极处理均成功治愈,无死亡病例。结论早期外科手术、术中采用冷刮吸法耐心处理胆囊三角,必要时中转开腹,术后密切观察是保证AGC成功治愈的关键。     

复杂性胆囊结石腹腔镜治疗体会

目的总结复杂性胆囊结石的腹腔镜手术治疗体会,探讨其安全性和可行性。方法对2009年5月～2012年5月行腹腔镜胆囊切除术的75例复杂性胆囊结石患者的临床资料进行回顾性分析。其中,急性胆囊炎48例,坏疽性胆囊炎12例,萎缩性胆囊炎5例,合并肝硬化5例,胆囊十二指肠瘘1例,Mirizzi综合征1例,合并腹部手术史3例。结果本组手术时间52～180 min,平均(67.5±35.5)min;术中出血量50～140 ml,平均(75.3±55.5)ml;术后住院时间5～30 d,平均(6.5±2.0)d。完成腹腔镜手术73例,其中腹腔镜下顺行胆囊切除术67例,顺逆结合胆囊切除4例,胆囊大部分切除2例。中转开腹2例,1例为胆总管损伤,行开腹胆囊切除加胆总管T管引流,另1例为右肝管和胆囊管并行过长解剖不清同时合并术中出血;术后并发急性脑梗塞1例。无术后大出血、胆瘘、腹腔脓肿、肠梗阻等并发症发生。结论充分的术前准备,术中仔细操作,及时中转开腹,以及认真细致地术后处理,腹腔镜治疗复杂性胆囊结石是安全可行的。     

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。     

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。     

腹腔镜胆囊切除术及部分切除术治疗胆囊复杂疾病的对比研究

目的:探讨腹腔镜胆囊部分切除术在胆囊复杂疾病患者中的应用价值。方法:将2009年1月至2013年1月收治的80例胆囊复杂疾病患者随机分为两组,每组40例,A组行腹腔镜胆囊部分切除术,B组行腹腔镜胆囊切除术。观察两组临床疗效及术后并发症发生情况。结果:两组手术时间差异无统计学意义(P>0.05);B组术中出血量[(86.4±11.6)ml]显著高于A组[(44.9±16.1)ml](P<0.05)。B组7例中转开腹,8例术后发生并发症;A组1例中转开腹,术后1例发生并发症,两组相比差异均有统计学意义(P<0.05)。A组中急性化脓性胆囊炎、急性坏疽性胆囊炎、慢性萎缩性胆囊炎患者间的术中出血量、手术时间、中转开腹情况及术后并发症等方面差异均无统计学意义(P>0.05)。结论:腹腔镜胆囊部分切除术治疗复杂胆囊病变可减少术中出血,有效避免中转开腹,减少术后并发症的发生。     

Early laparoscopic cholecystectomy is the appropriate management for acute gangrenous cholecystitis

Treatment of severe acute cholecystitis by laparoscopic cholecystectomy remains controversial because of technical difficulties and high rates of complications. We determined whether early laparoscopic cholecystectomy is appropriate for acute gangrenous cholecystitis. The medical records of 116 patients with acute gangrenous cholecystitis admitted to the Korea University Guro Hospital between January 2005 and December 2009 were reviewed. The early operation group, those patients who had cholecystectomies within 4 days of the diagnosis, was compared with the delayed operation group, who had cholecystectomies 4 days after the diagnosis. Of the 116 patients, 57 were in the early operation group and 59 were in the delayed operation group. There were no statistical differences between the groups with respect to gender, age, body mass index, operative methods, major complications, duration of symptoms, mean operative time (98 vs 107 minutes), or postoperative hospital stay. However, the total hospital stay was significantly longer in the delayed operation group. More patients underwent preoperative percutaneous cholecystostomy in the delayed operation group (3.5 vs 15.3%). Early laparoscopic cholecystectomy for acute gangrenous cholecystitis is safe and feasible. There is no advantage to postponing an urgent operation in patients with acute gangrenous cholecystitis.     

Early laparoscopic cholecystectomy for acute gangrenous cholecystitis

Treatment of severe acute cholecystitis by laparoscopic cholecystectomy remains controversial because of technical difficulties and high rates of complications and conversion to open cholecystectomy. We investigated whether early laparoscopic cholecystectomy is appropriate for acute gangrenous cholecystitis. Pathologic diagnoses and outcomes were analyzed in patients who underwent laparoscopic or open cholecystectomy at our hospital, January 2002 to September 2005. Of 30 patients with acute gangrenous cholecystitis, 16 underwent early laparoscopic cholecystectomy, 10 underwent open cholecystectomy, and 4 were converted to open cholecystectomy (conversion rate, 20.0%). There was no significant difference in operation time or intraoperative bleeding. The requirement for postoperative analgesics was significantly lower (6.4+/-7.3 vs. 1.5+/-1.2 doses, P<0.05) and hospital stay significantly shorter (8.6+/-2.1 vs. 15.6+/-6.3 d, P<0.01) after laparoscopic cholecystectomy. There were no postoperative complications in either group. Thus, early laparoscopic cholecystectomy seems appropriate for acute gangrenous cholecystitis. Conversion to open cholecystectomy may be required in difficult cases with complications.     

腹腔镜胆囊大部切除治疗急性坏疽性胆囊炎的临床分析

目的 探讨腹腔镜胆囊大部切除治疗急性坏疽性胆囊炎的临床疗效.方法 回顾120例急性坏疽性胆囊炎患者实施腹腔镜胆囊大部切除术后、观察其疗效及并发症的发生率.结果 120例急性坏疽性胆囊炎患者均成功施行腹腔镜胆囊大部切除、手术成功率为100%.平均手术时间(60.2±29.2) min、平均住院时间4～7 d、平均引流管留置时间2～5 d.术后无并发症发生.除择期手术组与急诊手术组手术时间(35.0±10.0) min vs.(55.0±12.0) min两组差异有统计学意义,P<0.05外,其他无统计学意义.结论 腹腔镜胆囊大部切除术治疗急性坏疽性胆囊炎是安全、有效的方法之一.     

Laparoscopic cholecystectomy for acute inflammation of the gallbladder.

OBJECTIVE. The aim of this study was to prospectively assess the results of laparoscopic cholecystectomy in patients with acute inflammation of the gallbladder. SUMMARY BACKGROUND DATA. Laparoscopic cholecystectomy has become the standard treatment for symptomatic gallbladder disease. Its role in the surgical treatment of acute cholecystitis has not been defined, although a number of recent reports suggest that there should be few contraindications to an initial laparoscopic approach. METHODS. All patients presenting with symptomatic cholelithiasis from October 1990 until June 1992 were evaluated at laparoscopy with intention of proceeding to a laparoscopic cholecystectomy. The gross appearance of the gallbladder was categorized as acute inflammation, chronic inflammation, or no inflammation. Ninety-eight (23.4%) of 418 patients had acute inflammation of the gallbladder: 55 were edematous, 10 were gangrenous, 15 had a mucocele, and 18 had an empyema. RESULTS. The authors assessed outcome in these patients. The frequency of conversion to an open operation was 33.7% for acute inflammation, 21.7% for chronic inflammation (p < 0.05), and 4% for no inflammation (p < 0.001). The conversion rate was highest for empyema (83.3%) and gangrenous cholecystitis (50%), while the conversion rate for edematous cholecystitis was 21.8% and for acute inflammation with a mucocele it was 7%. The median operation time for successful laparoscopic cholecystectomy for acute inflammation was 105 minutes, which was longer than that with no inflammation (90 minutes). However, the incidence of complications was not different from that for chronic or no inflammation. The median postoperative stay for patients with acute gallbladder inflammation was 2 days for successful laparoscopic cholecystectomy and 7 days for patients converted to an open operation. CONCLUSIONS. Laparoscopic cholecystectomy for acute inflammation of the gallbladder is safe and is associated with a significantly shorter postoperative stay compared to open surgery. A greater number of patients required conversion to open operation compared to those with no obvious inflammation. Conversion to open operation was most frequent for empyema and gangrenous cholecystitis, suggesting that once this diagnosis is made, excessive time should not be spent in laparoscopic trial dissection before converting to an open operation.     

腹腔镜治疗重型胆囊炎的临床研究

目的 :探讨重型胆囊炎腹腔镜治疗的可行性和手术方法。方法 :回顾分析腹腔镜手术治疗重型胆囊炎 80例的临床资料。结果 :79例实施LC成功 ,1例中转手术 ,无术中及术后并发症 ,手术时间 1～ 3h ,术中置腹腔引流管 ,术后恢复顺利。结论 :腹腔镜治疗重型胆囊炎可行 ,效果可靠     

腹腔镜胆囊大部切除术456例报告

目的探讨对难处理的结石性胆囊炎患者经腹腔镜施行胆囊大部切除术的效果。方法1998年1月至2008年6月对456例难处理的结石性胆囊炎（急性胆囊炎35例，慢性结石性胆囊炎急性发伴嵌顿350例，坏疽性胆囊炎26例，萎缩性胆囊炎40例，Murizzi综合5例），采用经腹腔镜施行胆囊大部切除术。结果患者都顺利完成腹腔镜胆囊大部切除术，手术未发生胆管损伤，大出血及中转开腹，随访1月～10年无异常发现。结论对难处理的结石性胆囊炎患者施行腹腔镜胆囊大部切除术是一种具有预防医源性胆道损伤，避免术中导致大出血而中转开腹的微创手术方法。     

Laparoscopic cholecystectomy: relationship of pathology and operative time.

OBJECTIVE: Controversy exists regarding the use and timing of laparoscopic cholecystectomy in the treatment of both acute and chronic cholecystitis. Acute advocates claim to avoid fibrosis and potential dissection injuries, whereas chronic proponents avoid poor visualization due to edema and possible conversion. This study of both acute and chronic cholecystitis cases examines the relationships between pathology, operative time, and outcome of laparoscopic cholecystectomy. METHODS: A retrospective review of medical records and pathology of acute (n = 9) and chronic (n = 62) laparoscopic cholecystectomy cases, performed by 2 surgeons from 1995 to 1999 was undertaken. Using multiple regression techniques, the relationship between operative time and age, sex, race, presenting symptoms, and degree of pathologic cholecystitis was evaluated. RESULTS: One case of acute gangrenous cholecystitis required conversion. None of the chronic cases required conversion. In single variable analysis, abnormal liver function tests, chronic inflammation, wall thickness, and number of stones were each predictive of longer operative time. However, in the multiple regression, abnormal liver function tests were the only clinical factor that remained a predictor of operative time (16 minutes longer, P = 0.05). Time from presentation to operation had no effect on operative time. Twelve patients had preoperative endoscopic retrograde cholangiopancreatography, and 4 had choledocholithiasis (acute n = 1, chronic n = 3). Two chronic patients required postoperative endoscopy for a cystic duct leak (n = 1) and choledocholithiasis (n = 1). The adjusted average operative time for acute and chronic cases was similar (93 versus 74 minutes, P > 0.05). CONCLUSION: Laparoscopic cholecystectomy can be done safely for both acute and chronic cholecystitis with similar operative times. Abnormal liver function tests are associated with longer operative time. Time lapse between presentation and operation has no effect on operative time or outcome.