腹腔镜胆囊切除术转开腹的相关危险因素研究

分析腹腔镜胆囊切除术转开腹的危险因素对术前病例的选择有重要意义.就腹腔镜胆囊切除术的危险因素作一综述,并探讨其增加手术难度的原因,旨在帮助术前腹腔镜胆囊切除术病例的选择.     

预测性评分系统在降低腹腔镜胆囊切除术中转开腹率中应用探讨

［摘要］ 目的 探讨以全身炎症反应及影像学作评分系统在降低腹腔镜胆囊切除术中转开腹率的可行性。方法 回顾性分析我院2009年2月~2015年2月所收治发病时间≤72 h的急性结石性胆囊炎行手术治疗892例患者的临床资料,并以前后3年分成A、B两组,以全身炎症反应及影像学作系统评分,探讨预测性评分系统在腹腔镜胆囊切除术中对中转开腹率的影响。结果 892例患者均接受手术治疗,未出现术中、术后死亡病例。A、B两组患者在年龄、性别及体重指数上的组间差异均无统计学意义（P>0.05）。在892例患者中,体温≥38.5℃、腹膜炎体征、白细胞计数≥18.0×109/L、C-反应蛋白≥30.0 mg/L、胆囊壁厚度≥0.8 cm的组别有着更高的中转开腹率,组间差异均有显著的统计学意义（P<0.001）。以全身炎症反应及影像学作系统评分作术前评估,并以前后3年中转开腹率作对比,有显著差异（P<0.05）。结论 以全身炎症反应及影像学作系统评分作术前评估能有效降低中转开腹率。     

腹腔镜胆囊切除术和开腹胆囊切除术安全性临床分析

目的比较开腹胆囊切除术和腹腔镜胆囊切除术的安全性。方法回顾分析568例胆囊切除术病例。分为2组:A组为对照组,323例行开腹胆囊切除术;B组为实验组,245例行腹腔镜胆囊切除术。对比2组的手术成功率、手术时间、住院时间、术中及术后并发症发生情况。2组手术成功率之间比较用检验,2组手术时间和住院时间之间比较用t检验,P0.05差异有统计学意义。结果2组手术成功率之间,P0.05,差异无统计学意义;2组手术时间和住院时间之间比较,P0.05差异有统计学意义。结论术前正确选择病例、术中规范操作、术后注意观察可能出现的并发症是腹腔镜胆囊切除手术成功的关键。相比开腹手术而言,具有明显的优势。     

腹腔镜胆囊切除术中转开腹危险因素的分析

目的分析腹腔镜胆囊切除术(LC)中转开腹的危险因素,为在保证安全前提下,降低中转开腹率提供参考。方法回顾分析328例LC患者的临床资料,采用Logistic回归分析方法,分析LC中转开腹的危险因素。结果 328例LC患者中转开腹26例,占7.93%,主要原因是Calot三角解剖不清(12/26,46.12%),腹腔粘连(9/26,34.62%)。墨菲氏征阳性、胆囊壁厚≥3mm、近6个月发作频数≥2次和黄疸为中转开腹的危险因素。结论对存在危险因素的患者,应术前做好中转开腹和适时选择开腹手术的准备。     

腹腔镜胆囊切除术中转开腹的危险因素分析

目的:分析腹腔镜胆囊切除术中转开腹的原因及相关危险因素,为外科医生的临床决策提供参考。方法:回顾分析3 476例腹腔镜胆囊切除术患者的临床资料,采用单因素分析及多因素logistic回归分析,探讨影响中转开腹的危险因素,并用SPSS 13.0绘制历年中转开腹率趋势图。结果:3 476例患者中,163例中转开腹,中转开腹率为4.7%;中转开腹组与腹腔镜组手术时间、术中出血量、术后住院时间、术后排气时间差异有统计学意义(P<0.05);胆囊粘连严重、胆囊三角处理困难是中转开腹的主要原因,占所有因素的57.1%;单因素分析结果显示:肥胖、手术经验、腹部手术史、胆囊炎反复发作史、胆囊壁厚度、WBC计数与腹腔镜胆囊切除术中转开腹相关(P<0.05);多因素分析结果显示:腹部手术史、肥胖、胆囊炎反复发作史、手术经验、胆囊壁厚度是影响腹腔镜胆囊切除手术中转开腹的独立危险因素(P<0.05)。结论:术前正确评估腹腔镜胆囊切除术中转开腹的相关危险因素,可为外科医生术中决策提供一定的参考,并可减少手术并发症。     

腹腔镜胆囊切除术中转开腹相关因素的分析

目的:探讨腹腔镜胆囊切除术中转开腹的相关因素.方法:随机选择2004年2月至2010年12月640例腹腔镜胆囊切除术患者作为研究对象,将腹腔镜胆囊切除术中转开腹患者作为观察组,将未中转开腹的患者作为对照组,对可能的影响因素先行单因素分析,再行.logistic回归分析.结果:腹腔镜胆囊切除术中转开腹40例;单因素分析1...     

腹腔镜与开腹胆囊切除术的住院费用对比

目的　比较腹腔镜与开腹胆囊切除术的住院费用。　方法　LC开展初期 ( 1991年 )和成熟期 ( 2 0 0 0年 )选取LC10 0例与同一时期开腹胆囊切除术 (OC) 10 0例住院费用进行对比分析。　结果　LC开展初期 ,LC组住院费用总费用( 2 575 86± 2 61 61)元明显高于OC组 ( 12 40 61± 3 82 67)元 (t=2 8 80 5,P <0 0 0 1) ,主要与手术及材料费用高 (t =199 83 3 ,P <0 0 0 1)有关。LC开展成熟期 ,LC组住院费用总支出 ( 583 3 0 0± 464 97)元明显低于OC组 ( 7489 2 6± 2 491 2 4)元 (t=6 53 5,P <0 0 0 1) ,虽然手术及材料支出仍高 (t=17 0 2 9,P <0 0 0 1) ,但药品、床位、检查等项均低于OC组 (t值分别为 8 83 9、12 0 0 5、6 2 0 3 ,P <0 0 0 1)。　结论　随着LC技术的成熟 ,费用降低已成为其一大特点     

腹腔镜胆囊切除术转开腹手术的危险因素分析

目的研究多个临床因素对腹腔镜胆囊切除术(LC)转开腹手术的影响。方法对浙江大学医学院附属邵逸夫医院1994年4月至2001年6月的7134例LC的临床资料进行单因素分析,再进行多元逻辑回归分析(逐步排除法),得出影响LC转开腹手术的独立的危险因素。结果男性、高龄(≥65岁)、上腹部手术史、糖尿病、总胆红素升高(≥20.5μmol/L)、胆囊壁增厚(≥4mm)、胆总管直径增宽(≥8mm)、急性胆囊炎是转开腹手术的危险因素。结论可以根据转开腹手术的危险因素指导临床工作。     

腹腔镜胆囊切除术中转开腹原因分析及对策

LC中转开腹是保证LC安全的重要手段，我们分析我院LC中转开腹的原因，探讨在保证安全前提下如何降低中转开腹率。     

腹腔镜胆囊切除术与开腹胆囊切除术的临床比较研究

目的比较腹腔镜胆囊切除术与开腹胆囊切除术的疗效和安全性。方法将我院2008年6月～2010年6月收治的96例胆囊疾病患者随机分为观察组（腹腔镜胆囊切除术）和对照组（开腹胆囊切除术）各48例,术后比较两组的手术时间、术中出血量、术后排气时间及并发症情况。结果观察组的手术用时、排气时间、住院时间明显短于对照组（P〈0.05）,且观察组术中出血量明显少于对照组（P〈0.05）,术后观察组1例因胆囊三角区出血,镜下止血失败而中转开腹;1例术后伤口出现感染,对照组出现切口感染4例,胆心反射5例,切口出血4例,胆管损伤、肠粘连各1例,观察组术后并发症的发生率明显低于对照组并发症的发生率（P〈0.05）。结论腹腔镜胆囊切除术与传统开腹手术相比对患者损伤小,术后恢复快,住院时间短,但也存在一些术后并发症,但并发症的发生率较低。     

Risk factors for conversion of laparoscopic cholecystectomy to open cholecystectomy

Background Conversion to open cholecystectomy is still required in some patients. The aim of this study was to evaluate preoperative factors associated with conversion to open cholecystectomy in elective cholecystectomy and acute cholecystitis.Methods The records of 1,804 patients who underwent cholecystectomy from May 1992 to January 2004 were reviewed retrospectively. The demographics and preoperative data of patients who required conversion to laparotomy were compared to those with successful laparoscopic cholecystectomy.Results Conversion to open cholecystectomy was needed in 94 patients (5.2%),of which 44 (2.8%) had no inflammation and 50 (18.4%) had acute inflammation of the gallbladder. Male gender, age older than 60 years, previous upper abdominal surgery, diabetes, and severity of inflammation were all significantly correlated with an increased conversion rate to laparotomy. Also, the conversion from laparoscopic to open cholecystectomy in acute cholecystitis patients was associated with greater white blood cell count, fever, elevated total bilirubin, aspartate transaminase, and alanine transaminase levels, and the various types of inflammation.Conclusions None of these risk factors were contraindications to laparoscopic cholecystectomy. This may help predict the difficulty of the procedure and permit the surgeon to better inform patients about the risk of conversion from laparoscopic to open cholecystectomy.     

万例腹腔镜胆囊切除术中转开腹原因分析(附156例报告)

目的 探讨腹腔镜胆囊切除术(LC)中转开腹的原因。方法 对我院1991年12月-2001年10月实施的12672例LC中转开腹手术156例进行回顾性分析。结果 中转开腹率1．23％(156／12672)，术中因病情复杂及术前误诊所致的被迫性开腹92例(58．97％)，术中因出现技术性并发症而导致强迫性开腹47例(30．13％)，延期开腹17例(10．90％)，胆管损伤率0．2％(26／12672)。结论 LC中转开腹主要原因为术前准备不充分，术经验不足，病变复杂，胆道解剖变异。     

腹腔镜胆囊切除术中转开腹手术105例临床分析

目的探讨腹腔镜胆囊切除术(LC)中转开腹的原因及防治措施。方法回顾性分析2003年1月至2012年12月我科收治3047例LC中105例中转开腹的临床资料,分析其中转开腹的原因并总结。结果本组患者的中转开腹率为3.45%,分析原因主要为胆囊三角严重粘连、解剖困难、胆囊管结石嵌顿、胆管损伤、大出血、意外胆囊癌等,105例患者经中转开腹后无严重并发症,均痊愈出院。结论准确严格把握LC手术适应证,术中规范、精细操作可有效降低中转开腹率,而当操作困难或对手术没把握时,应及时中转开腹以确保手术安全性。     

A difficult laparoscopic cholecystectomy that requires conversion to open procedure can be predicted by preoperative ultrasonography.

A prospective study was conducted from March 1999 to April 2000 that included 73 patients who underwent elective laparoscopic cholecystectomy for uncomplicated gallstone disease. The study was conducted at one surgical unit in the Department of Surgery and Department of Radio-diagnosis and one surgical unit in the Department of Surgery, Maulana Azad Medical College and the associated Lok Nayak Hospital, which is the largest referral hospital in northern India and is located in the capital of India. A preoperative ultrasound was performed just prior to surgery, and 4 ultrasonographic parameters were analyzed. namely gallbladder wall thickness, contracted gallbladder, impaction of gallstones at the neck of the gallbladder, and common bile duct stones. The surgical findings were objectively graded as difficult or easy laparoscopic cholecystectomy according to 5 operative parameters, namely total time taken for the surgery, time taken to dissect gallbladder bed, spillage of stones, tear of gallbladder during dissection, and conversion to the open procedure. Of the 73 cases, 17 (23.3%) were conversions to the open procedure. Of the 21 (28.76%) cases predicted to be difficult, 17 (23.3%) were technically difficult, of which 13 (17.8%) were converted to the open procedure. Of the 52 (71.23%) cases predicted to be easy on ultrasonography, only 7 (9.38%) were found to be difficult on surgery, of which only 4 (5.48%) had to be converted to the open procedure. Based on our results, we conclude that preoperative ultrasonography is of great value in selecting patients preoperatively for laparoscopic cholecystectomy and minimizing complications and conversion to the open procedure.     

Laparoscopic cholecystostomy with delayed cholecystectomy as an alternative to conversion to open procedure

Background: Acute cholecystitis carries the highest incidence of conversion from planned laparoscopic cholecystectomy to open surgery due to unclear anatomy, excessive bleeding, complications, or other technical reasons. Methods: Laparoscopic tube cholecystostomy was performed instead of immediate conversion to laparotomy in 9 patients with acute cholecystitis after unsuccessful attempts at laparoscopic dissection. Elective laparoscopic cholecystectomy was done 3 months later. Results: Following this approach eight patients were treated successfully. After 3 months the acute process had subsided sufficiently to allow a safe laparoscopic cholecystectomy. One additional patient died of acute leukemia 6 weeks after cholecystostomy. Before adopting this technique we subjected 171 patients with acute calculous cholecystitis to laparoscopic cholecystectomy; there was an 11% (19 cases) rate of conversion. Since cholecystostomy has begun to be offered as an alternative to conversion, 121 patients with acute cholecystitis have had laparoscopic cholecystectomy and only 2 cases (1.5%) have been converted to immediate open cholecystectomy. Conclusions: We recommend the alternative of performing a cholecystostomy with delayed laparoscopic cholecystectomy instead of conversion to open procedure when facing a case of acute cholecystitis not amenable to laparoscopic cholecystectomy.     

The pre-operative predictive model for difficult elective laparoscopic cholecystectomy: A modification

BackgroundAlthough LC is a common operation, difficult cases are still challenging. Several studies have identified factors for the difficulty and conversion. Many scoring systems have been established for pre-operative prediction. This study aimed to investigate significant factors and validity of Randhawa’s model in our setting.MethodsThis prospective study enrolled LC patients in Hepato-Pancreato-Biliary Surgery unit between March 2018 and October 2019. The difficulty of operation was categorized into 3 groups by intra-operative grading scale. Multivariate analysis was performed to define significant factors of very-difficult and converted cases. The difficulty predicted by Randhawa’s model were compared with actual outcome. Area under ROC curve was calculated.ResultsAmong 152 patients, difficult and very-difficult groups were 59.2% and 15.1%, respectively. Sixteen cases needed conversion. Four factors (cholecystitis, ERCP, thickened wall, contracted gallbladder) for very-difficult group and 3 factors (obesity, biliary inflammation or procedure, contracted gallbladder) for conversion were significant. After some modification of Randhawa’s model, the modified scoring system provided better prediction in terms of higher correlation coefficient (0.41 vs 0.35) and higher AUROC curve (0.82 vs 0.75) than original model.DiscussionRandhawa’s model was feasible for pre-operative preparation. The modification of this model provided better prediction on difficult cases.     

腹腔镜胆囊切除术中转开腹25例分析

目的探讨腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）中转开腹的预防。方法回顾性分析我院1999年12月～2005年10月852例LC中中转开腹手术25例的临床资料。中转原因：胆管损伤3例,出血1例,腹腔、胆囊周围粘连9例,胆囊三角解剖不清5例,胆囊十二指肠瘘2例,Mirizzi综合征Ⅱ型5例。结果中转开腹手术均获成功,无并发症。随访1～2年,无胆道狭窄。结论重视术前对胆囊病变程度的判断以及术中采取预防措施可减少中转开腹。     

Laparoscopic cholecystectomy

In 1,300 patients undergoing laparoscopic cholecystectomy (LC) 56 patients (4.3%) required conversion to open cholecystectomy (OC); 41 (73%) of the conversions were elective, whereas 15 (27%) were enforced. The causes of the 56 conversions are described and analyzed. Logistic regression analysis of 23 parameters identified the following data as associated with a higher risk for conversion: pain or rigidity in the right upper abdomen (P<0.01), thickening of the gallbladder wall on preoperative ultrasound (P<0.05), intraoperatively found dense adhesions to the gallbladder or in Calot's triangle (P<0.001), and intraoperatively found acute inflammation of the gallbladder (P<0.01). Clinical findings of an acute cholecystitis associated with intraoperative dense scarring in Calot's triangle were the best factors predicting conversion from LC to OC. As a result of the study we preoperatively select our patients for either LC or OC, and a difficult case is performed by a more experienced surgeon to keep conversion rate and complications low.