经腹腔镜胆囊切除术1650例的经验

本文报告我院为各种类型的胆囊良性疾病患者行腹腔镜胆囊切除术（ＬＣ）１６５０例，中转手术３２例，发生各种并发症３１例，其中肝外胆管损伤４例，术后需剖腹止血３例，胆囊管残端瘘１例。治愈１６４９例，死亡１例。重点讨论ＬＣ手术的并发症与学习曲线，中转开腹手术指征，强调ＬＣ术中正确辩论胆囊壶腹与胆囊管交界部在预防肝外胆管损伤中的作用和地位。     

腹腔镜胆囊切除术中转开腹手术的原因分析

目的探讨腹腔镜胆囊切除术（LC）中转开腹手术的原因。方法采用回顾性分析的方法对30例LC中转开腹手术原因进行统计分析。结果中转开腹手术的原因中，手术部位解剖关系不清16例（53．3％），解剖结构异常6例（20．0％），胆囊床广泛渗血不止4例（13．3％），胆囊动脉出血3例（10．0％），肝外胆管损伤1例（3．3％）。结论腔镜手术操作困难时应及时中转开腹手术，以获得最好的远期疗效。术前仔细评估，严格腹腔镜手术指征，术中仔细精准的解剖定位，可以降低中转开腹手术率。     

腹腔镜胆囊切除术并发症的防治

为了提高腹腔镜胆囊切除术（ＬＣ）的安全性，作者对６００例ＬＣ的并发症加以回顾性总结。结果全组共发生并发症２９例（术中１４例，术后１５例），占４．８３％，包括胆管损伤２例，出血９例，皮下气肿２例及胃窦穿孔１例。中转剖腹１４例，其中因术中出现并发症中转４例，因术后并发症再手术２例，全组均治愈出院。因此，及时中转剖腹是避免严重并发症的重要措施，为了积极稳妥地开展ＬＣ手术，手术并发症的防治值得重视。     

腹腔镜胆囊切除术并发症的防治

为了提高腹腔镜胆囊切除术（ＬＣ）的安全性，作者对６００例ＬＣ的并发症加以回顾性总结。结果全组共发生并发症２９例（术中１４例，术后１５例），占４．８３％，包括胆管损伤２例，出血９例，皮下气肿２例及胃窦穿孔１例。中转剖腹１４例，其中因术中出现并发症中转４例，因术后并发症再手术２例，全组均治愈出院。因此，及时中转剖腹是避免严重并发症的重要措施，为了积极稳妥地开展ＬＣ手术，手术并发症的防治值得重视。     

单中心腹腔镜胆囊切除致胆管损伤近年变化及特点分析

目的总结单中心腹腔镜胆囊切除致胆管损伤近年的变化及特点。方法回顾性分析总结近期组（2003年6月至2009年3月）和早期组（1992年10月至1998年6月）进行腹腔镜胆囊切除术（LC）患者的临床资料,并进行对比分析。结果近期组18613例中发生胆管损伤11例（发生率0．06％）,包括胆管横断伤2例（1例是中转开腹以后发生）、胆管分离性损伤3例、电凝伤2例（肝总管1例、副肝管1例）、胆总管部分剪切伤2例、副肝管横断伤1例、中转开腹肝总管部分缝扎伤1例;早期组11796例中发生胆管损伤15例（发生率0．13％）,包括横断伤6例、电灼胆管侧壁伤6例、分离伤3例。近期组LC致胆管损伤的发生率明显低于早期组（χ2=3．92,P=0．04784）。结论近期组Lc致胆管损伤的发生率较早期组明显降低,损伤程度也在降低,但损伤种类在不断增加,依据胆管损伤的类型进行“个体化”处理可减少胆管进一步损伤以及术后并发症的发生。     

腹腔镜胆囊切除术治疗急性胆囊炎的效果分析

目的探讨急性胆囊炎患者行腹腔镜胆囊切除术的效果。方法分析2009年1月—2012年6月在我院住院的40例急性胆囊炎行腹腔镜胆囊切除术患者的临床资料。结果 40例患者中34例完成腹腔镜胆囊切除术,6例中转开腹手术;患者均无胆漏及肝外胆管损伤等并发症,无死亡病例。结论随着腹腔镜技术的日益成熟和手术经验积累,急性胆囊炎行腹腔镜胆囊切除术是安全可行的,且局部创伤小、手术时间短、全身反应轻、脏器功能恢复快。     

胆囊切除术中高位胆管损伤的原因和治疗

胆囊切除术中高位胆管损伤的原因和治疗淄博矿务局中心医院（２５５１２０）季新海葛永明１９８３年以来，我们收治胆囊切除术中高位胆管损伤患者１６例，效果满意。现报告如下。１临床资料１．１一般资料本组男７例，女９例；年龄２６～５７岁，平均４１岁。损伤部位在肝...     

腹腔镜胆囊切除术严重手术并发症的预防

目的评价腹腔镜胆囊切除术（ＬＣ）的安全性和有效性，对２８８０例ＬＣ及其并发症的预防加以总结．方法对２８８０例良性胆囊疾病患者行ＬＣ，术前选择性地行ＥＲＣＰ等影像学检查．结果ＬＣ时中转开腹胆囊切除术１２３例（４３％），中转原因多为Ｃａｌｏｔ三角粘连严重，解剖结构不清楚．共发生各种并发症２１例（０７２％），其中胆漏４例，出血３例，膈下积液５例，十二指肠穿孔１例，胆总管残留结石８例，均治愈．无手术死亡病例，也无胆道损伤等严重并发症发生．结论手术者的胆道外科素质，选择性术前ＥＲＣＰ检查，慎重细致的手术操作，是预防胆道损伤等严重手术并发症发生的重要因素．     

腹腔镜下胆囊切除术1650例无胆管损伤的体会

目的 探讨如何预防腹腔镜胆囊切除术中胆管损伤。方法 回顾1995-10／2004-12间1650例腹腔镜胆囊切除手术病例的临床资料进行分析。结果 17例因胆囊Calot三角严重黏连、胆囊萎缩而中转开腹。1650例无一例胆管损伤并发症。术后2-6d出院，平均4d。结论 开展腹腔镜胆囊切除术应适当选择病例，仔细处理Calot三角，适时中转开腹是预防胆管损伤的重要措施。     

腹腔镜胆囊切除术中肝外胆管横断损伤原因及对策

目的　探讨腹腔镜胆囊切除术中肝外胆管横断损伤发生的原因及预防措施。方法　回顾分析了６ ０００ 例腹腔镜胆囊切除术中９例肝外胆管横断损伤的原因,探讨了预防肝外胆管横断损伤的措施。结果　指出Ｃａｌｏｔ三角解剖结构不清或存在解剖变异,误把胆总管当胆囊管钳夹、切断是肝外胆管横断损伤的主要原因。结论　严格掌握手术适应证,沿胆囊壶腹向下分离,仔细辨别Ｃａｌｏｔ三角解剖结构,术中始终想着Ｃａｌｏｔ三角解剖结构存在的变异,避免盲目自信、莽撞行事是预防肝外胆管横断损伤的关键。     

基层医院行腔镜胆囊切除术66例体会

目的：总结基层医院行腹腔镜胆囊切除术（ LC）的体会。方法对2010-10～2013-09在该院因复杂胆囊病变施行LC手术的66例患者的临床资料进行回顾性分析。结果本组64例在腹腔镜下完成手术,2例患者中转开腹,术后胆漏1例,再次手术。66例患者均顺利康复出院。结论基层医院行LC手术初期必须加强基本功训练,严格选择病例及适应证;术中精心操作,处理好胆囊动脉及胆囊管,遇到困难可采取及时中转开腹手术等措施,确保手术安全;术后严密观察,发现问题及时处理。     

不同Calot三角解剖入路腹腔镜胆囊切除术治疗胆囊结石伴慢性胆囊炎患者疗效对比分析

目的 比较不同Calot三角解剖入路在腹腔镜胆囊切除术（LC）中的应用效果。方法 根据不同Calot三角解剖入路方式分组,在行LC术治疗胆囊结石伴慢性胆囊炎患者时,100例采用胆囊后三角解剖入路（观察组）,另100例采用胆囊三角入路（对照组）,采用免疫比浊法测定血清C反应蛋白（CRP）,采用ELISA法测定血清白细胞介素-6（IL-6）、白介素-8（IL-8）和肿瘤坏死因子-α（TNF-α）水平,采用视觉模拟评分（VAS）工具评估疼痛程度,比较两组手术指标及手术前后血清细胞因子水平变化。结果 在手术中,发现观察组胆囊周围出现粘连53例,对照组50例;两组无胆囊粘连患者组间各手术指标、手术并发症和中转开腹发生率比较均无显著性差异（P>0.05）;观察组粘连患者手术时间、术中出血量、术后肠功能恢复时间、住院时间和术后VAS评分分别为（29.4±4.3） min、（33.9±4.6） ml、（26.0±4.2） h、（6.0±1.0） d和（4.0±1.5） 分,均显著少于或轻于对照组粘连患者【（59.1±5.5） min、（45.6±4.1） ml、（30.3±4.5） h、（8.4±1.0） d和（4.8±1.3） 分,P<0.05】;观察组胆囊粘连患者无并发症和中转开腹者,而对照组胆囊粘连患者则分别为8.0%和8.0%（P<0.05）;治疗后,观察组血清CRP、IL-6、IL-8和TNF-α水平均显著低于对照组（P<0.05）。结论 经胆囊后三角解剖入路行LC术能明显减少胆囊粘连患者术中出血量,显著降低并发症和中转开腹发生率。在LC术中需密切观察胆囊粘连与否及其程度等情况,而给予合理的处理。     

Laparoscopic cholecystectomy with full-thickness dissection for potentially cancerous lesions: comparison with standard technique

BACKGROUND/AIMS: With an increase in laparoscopic cholecystectomy (LC) cases, unsuspected gallbladder cancers have been reported and intraabdominal cancer dissemination has been identified as a crucial problem. Since September 1991, we employed LC with full-thickness dissection (LC-F) for polypoid lesions of the gallbladder. In the present study, the utility of the procedure was investigated. METHODOLOGY: For 261 patients who underwent standard LC (S-LC) or LC-F between September 1991 and August 1996, the operation time, intra- and post-operative complications relevant to the operative technique, histological findings of the gallbladders, and prognosis of each patient with gallbladder cancer were evaluated. RESULTS: S-LC and LC-F were performed in 231 and 30 patients, respectively. The mean operation times for S-LC and LC-F were 157 and 120 min, respectively, (p < 0.05). Gallbladder perforation occurred in 29 S-LCs, whereas there was none in 30 LC-Fs (p < 0.05). Bleeding from the gallbladder bed occurred in 1 patient in each of the 2 groups, but was stopped easily. There was neither post-operative bleeding nor bile leakage in either group. Mucosal cancer was diagnosed in 3 gallbladders resected by S-LC and 1 resected by LC-F. One patient of the LC-F group with advanced cancer underwent laparotomy. All the patients have no signs of recurrence. CONCLUSIONS: LC-F allows the complete removal of the connective tissue of the gallbladder bed without perforation and, therefore, is considered as a safe and useful procedure for resecting gallbladders with potentially cancerous lesions.     

腹腔镜胆囊切除术治疗复杂性胆囊结石的评价

为了评价腹腔镜胆囊切除术（ＬＣ）治疗复杂性胆囊结石的有效性和安全性，本文对比分析了手术时间、中转开腹手术率、并发症发生率和住院时间等项指标。结果表明，单纯组和复杂组平均手术时间分别为３１．６和４５．７分钟（Ｐ＜０．０５）；中转开腹手术率分别为１．０％和７．４％（Ｐ＜０．０１）；住院时间复杂组长于单纯组。单纯组９９％的病人、复杂组９０％以上的患者能够采用ＬＣ治愈。两组术后并发症发生率无显著差异。两组总中转开腹手术率为２．７％。本文结果提示，ＬＣ用于治疗伴有各种并发症的复杂性胆囊结石是可行的，同样可以保留和体现出它的优越性。     

Laparoscopic cholecystectomy for acute cholecystitis

From October 1991 to March 1994, 35 patients (20 men and 15 women) with acute cholecystitis (AC) underwent laparoscopic cholecystectomy (LC). They ranged in age from 17 to 82 years (mean, 51.7 years). Nine of the 35 patients (25.7%) had either percutaneous transhepatic gallbladder drainage (PTGBD) or percutaneous transhepatic gallbladder aspiration (PTGBA) performed preoperatively. The mean operative time was 183.7 min. Four of the 35 patients (11.4%) required conversion to open laparotomy. The mean postoperative hospital stay was 11.2 days and postoperative morbidity rate was 2.9%. There were no major complications and no deaths. In this retrospective study, we divided the patients into three groups according to the surgical timing of LC in relation to onset. Two of the three groups had LC performed more than 7 days after onset; these groups were termed, collectively, the delayed LC group. The group that had LC performed within 7 days of onset we termed the early LC group. The early LC group had a shorter operative time, less blood loss, and a shorter postoperative hospital stay than the delayed LC group, but the differences were not significant. Nevertheless, we suggest that early LC for AC should be employed for patients who are in a stable condition and who have no preoperative associated medical problems. In the delayed LC group, there were no significant differences in findings between patients who received or did not receive either PTGBD or PTGBA. PTGBD and PTGBA are useful procedures for the relief of acute severe symptoms in patients whose condition is refractory to treatments such as i.v. antibiotic infusion and no oral feeding. We conclude that a laparoscopic procedure for patients with AC, when performed by experienced surgeons, is safe, technically feasible, and useful.     

Successful laparoscopic management for cholecystoenteric fistula

AIM: Since 1987, laparoscopic cholecystectomy (LC) has been widely used as the favored treatment for gallbladder lesions. Cholecystoenteric fistula (CF) is an uncommon complication of the gallbladder disease, which has been one of the reasons for the conversion from LC to open cholecystectomy. Here, we have reported four cases of CF managed successfully by laparoscopic approach without conversion to open cholecystectomy. METHODS: During the 4-year period from 2000 to 2004, the medical records of the four patients with CF treated successfully with laparoscopic management at the Chang Gung Memorial Hospital-Taipei were retrospectively reviewed. RESULTS: The study comprised two male and two female patients with ages ranging from 36 to 74 years (median: 53.5 years). All the four patients had right upper quadrant pain. Two of the four patients were detected with pneumobilia by abdominal ultrasonography. One patient was diagnosed with cholecystocolic fistula preoperatively correctly by endoscopic retrograde cholangiopancreatography and the other one was diagnosed as cholecystoduodenal fistula by magnetic resonance cholangiopancreatography. Correct preoperative diagnosis of CF was made in two of the four patients with 50% preoperative diagnostic rate. All the four patients underwent LC and closure of the fistula was carried out by using Endo-GIA successfully with uneventful postoperative courses. The hospital stay of the four patients ranged from 7 to 10 d (median, 8 d). CONCLUSION: CF is a known complication of chronic gallbladder disease that is traditionally considered as a contraindication to LC. Correct preoperative diagnosis of CF demands high index of suspicion and determines the success of laparoscopic management for the subset of patients. The difficult laparoscopic repair is safe and effective in the experienced hands of laparoscopic surgeons.     

Experience with three-port laparoscopic cholecystectomy

After considerable experience with laparoscopic cholecystectomy (LC) using four ports, we began using three-port LC in October 1993 and have performed 130 LCs with this procedure up to May 1996. The procedure was successful in 119 patients. In 6 patients fourth port was used, and in another 5, the procedure was converted to open laparo-tomy. Cooperative manipulation of the surgical instruments between the operator and assistant is very important for this procedure, for exposing Calot's triangle and dissecting the gallbladder from the gallbladder bed. The use of an ultrasonic aspiration system (Sumisonic ME 2400; Sumitomo Bakelite, Tokyo, Japan) made it easier to identify the cystic duct and artery, especially in patients with chronic inflammation or dense adhesions. We encountered no problems with cannulation into the cystic duct for intraoperative cholangiography, and there were no intra- and postoperative complications in this series. We achieved good results, similar to those achieved with the four-port technique. This technique is technically feasible and safe, and it has esthetic and cost advantages compared with the four-port technique. However, the operator who performs three-port LC should not hesitate to add another port, or to convert to open laparotomy, whenever any difficulties occur during this procedure, to prevent critical complications.     

瓷样胆囊的腹腔镜手术治疗

目的 探讨瓷样胆囊腹腔镜切除术治疗的诊断及方法.方法 对1980年1月至2005年1月瓷样胆囊患者28例资料进行回顾分析,重点分析经腹腔镜胆囊切除术治疗的17例瓷样胆囊.结果 28例瓷样胆囊占同期胆囊切除术患者的0.44%（28/6328）,B超诊断胆囊壁钙化率92.86%,17例经腹腔镜治疗的瓷样胆囊患者均痊愈出院,2例合并有胆囊癌的患者均没有发现切口种植转移.结论 瓷样胆囊有其特殊的B超影像,手术方式的改进以及技巧的熟练,是瓷样胆囊腹腔镜手术治疗成功的关键.