提高腹腔镜胆囊切除术的安全性探讨

腹腔镜胆囊切除术已成为胆囊良性疾病治疗的“金标准”,总结近年来各种确切的手术安全措施,建议重视围手术期影像学的检查和术前高危因素的处理,加强手术技巧的训练,积极引入加速康复外科理念,以尽可能的避免并发症的发生,提高腹腔镜胆囊切除术的安全性。     

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。     

腹腔镜胆囊切除术524例体会

20 0 0～ 2 0 0 2年 ,我们为 5 2 4例患者施行腹腔镜胆囊切除术 ( L C) ,现将体会报告如下。临床资料 :本组男 144例 ,女 3 80例 ,年龄 2 2～ 90岁。 B超检查示慢性胆囊炎伴结石 44 2例 ,胆囊良性隆起样病变 5 2例 ,萎缩性胆囊炎伴结石 18例 ,非结石性胆囊炎 12例。均采用 3 0°腹腔镜 ,标准四孔法完成 L C,其中中转开腹手术 16例。术中并发症 :胆总管横断 1例、胆囊床迷走胆管损伤 1例、出血 3例 ,均中转开腹处理 ,痊愈出院。术后胆囊管残端漏 1例、出血 1例 ,均再次手术处理 ;余患者均恢复顺利痊愈出院。讨论 :L C的优点为创伤小 ,患者…     

腹腔镜胆囊切除术

当前,全世界对腹腔镜胆囊切除术这一现代技术的兴趣呈爆炸性高涨。1992年医学文献索引罗列了230篇有关文章,1993年增加到557篇,1994年1月至9月有197篇。以这种技术为基础的新的协会、新的杂志大量涌现,国际性最新进展的研讨会也经常举行。 历史沿革 虽然人们普遍认为腹腔镜胆囊切除是7年前在法国“秘密”地诞生的,但事实上德国人已     

电视腹腔镜胆囊切除术的麻醉体会

20世纪80年代末开展了电视腹腔镜胆囊切除术(LPC)，90年代初我国各地也开展了这一新技术，此类手术具有切口小，创伤小的特点，但必须向腹腔充气使腹腔膨隆，以便于观察和操作，由于气腹而造成对机体正常生理功能的干扰是很大的。现将我们近4年来完成的100例电视腹腔镜胆囊切除手术的麻醉处理介绍如下。     

急性胆囊炎腹腔镜胆囊切除术的时机

目的 探讨急性胆炎腹腔镜胆囊切除术（ＬＣ）的可行性及手术时机。方法 回顾分析了我院１９９１年９月－１９９８年７月５８００例ＬＣ中３８６例急性胆囊炎患者（６．５％）腹痛发作时间与手术操作难易程度及中转开腹率高低关系。结果 发作４８小时以内者１９７例,１９２例完全了ＬＣ手术操作,平均手术时间３７分钟（１５￣７０分钟）,５便中转开腹（２．６％）;发作２￣６天者１８９例,１９例中转开腹（１０％）,１７０例     

腹腔镜胆囊切除术中转开腹原因探讨

我院自1997年~2002年3月共开展腹腔镜胆囊切除术(LC)1018例,术中因各种原因转开腹39例,中转率为3.8%。本文就提高LC成功率的措施及中转开腹指征讨论如下。     

腹腔镜下胆囊切除术96例手术配合体会

自1998年以来，我们共为63例患者于腹腔镜下行胆囊切除术，效果满意。现将手术配合体会报告如下。     

妊娠期腹腔镜胆囊切除术

腹腔镜胆囊切除术ｌａｐａｒｏｓｃｏｐｉｃｃｈｏｌｅｃｙｓｔｅｃｔｏｍｙＬＣ初期许多病例被认为是绝对禁忌。随着医疗设备的改进及临床经验的积累,一些绝对禁忌证变为了相对禁忌证,甚至不再是禁忌证。妊娠期胆囊结石并胆囊炎曾被认为是ＬＣ的绝对禁忌,但近年来不断有妊娠期ＬＣ术的成功病例报道。本文仅对妊娠期ＬＣ术作一简要综述。一、妊娠期胆囊结石特点受激素水平改变的影响,妊娠期胆囊排空能力降低,胆囊内胆盐与胆固醇处于过饱和状态,胆固醇易于在胆囊内沉积形成结石并表现为急、慢性胆囊炎１。绝大多数妊娠期症状性胆囊结石…     

Transvaginal cholecystectomy vs conventional laparoscopic cholecystectomy for gallbladder disease:A meta-analysis

AIM:To compare the results of transvaginal cholecystectomy(TVC) and conventional laparoscopic cholecystectomy(CLC) for gallbladder disease.METHODS:We performed a literature search of Pub Med,EMBASE,Ovid,Web of Science,Cochrane Library,Google Scholar,Meta Register of Controlled Trials,Chinese Medical Journal database and Wanfang Data for trials comparing outcomes between TVC and CLC.Data were extracted by two authors.Mean difference (MD), standardized mean difference(SMD),odds ratios and risk rate with 95%CIs were calculated using fixed- or random-effects models.Statistical heterogeneity was evaluated with the χ2 test.The fixed-effects model was used in the absence of statistically significant heterogeneity.The randomeffects model was chosen when heterogeneity was found.RESULTS:There were 730 patients in nine controlled clinical trials.No significant difference was found regarding demographic characteristics(P 0.5),including anesthetic risk score,age,body mass index,and abdominal surgical history between the TVC and CLC groups.Both groups had similar mortality,morbidity,and return to work after surgery.Patients in the TVC group had a lower pain score on postoperative day 1(SMD:-0.957,95%CI:-1.488 to-0.426,P 0.001),needed less postoperative analgesic medication(SMD:-0.574,95%CI:-0.807 to-0.341,P 0.001) and stayed for a shorter time in hospital(MD:-1.004 d,95%CI:-1.779 to 0.228,P = 0.011),but had longer operative time(MD:17.307 min,95%CI:6.789 to 27.826,P = 0.001).TVC had no significant influence on postoperative sexual function and quality of life.Better cosmetic results and satisfaction were achieved in the TVC group.CONCLUSION:TVC is safe and effective for gallbladder disease.However,vaginal injury might occur,and further trials are needed to compare TVC with CLC.     

Unexpected gallbladder cancer during laparoscopic cholecystectomy

Background/Purpose

In the present study, we investigated the effectiveness of surgeons in determining incidental gallbladder pathologies at laparoscopic cholecystectomy (LC).

Methods

This study included 548 patients with gallstones who underwent LC between May 1, 2001 and October 15, 2003. The surgeon made an incision on the gallbladder wall for inspection, and palpated the mucosa after removing the gallbladder from the abdominal cavity to look for unsuspected pathologies. If an abnormal mucosa was observed or palpated, it was marked with a silk suture and then histopathologic examination was performed.

Results

Fifty of 548 LC specimens were found to be suspi-cious by the surgeon. Histopathological examination of frozen sections revealed incidental pathologies in 15 of these specimens. Strikingly, 5 of these specimens were considered to have gallbladder cancer (GBC). The other incidental pathologies were consistent with adenomyomatosis, xanthogranulomatous cholecystitis, and fibroepithelial and hyperplastic polyps. Four of the other 498 specimens revealed incidental pathologies at definitive histopathological examination, and all of them were consistent with gastric metaplasia. The sensitivity and specificity of the procedure was 78.9% and 93%, respectively.

Conclusions

A simple prosedure; that is, incision and inspection, and palpation of the gallbladder, seems to be useful for the diagnosis of incidental gallbladder pathologies.

     

胆囊部分切除术治疗胆囊形态异常合并泥沙样结石性胆囊炎的效果分析

目的探讨腹腔镜下胆囊部分切除术治疗胆囊形态异常合并泥沙样结石性胆囊炎的应用价值。方法选取2010年7月-2014年1月于大连市友谊医院行腹腔镜联合胆道镜胆囊部分切除术治疗的胆囊形态异常合并泥沙样结石性胆囊炎患者18例。所有患者均伴有胆囊形态的异常,表现为胆囊折叠或胆囊腺肌症;病变部位皆位于胆囊的远端。术前将胆囊病变部分和正常胆囊拟保留部分分别做胆囊收缩试验。术中胆道镜检查胆囊管通畅,胆囊壁弹性好,无明显慢性炎症。切除有病变的胆囊后,4-0可吸收线连续两层缝合胆囊。计量资料组间比较采用独立样本t检验。结果所有患者手术均获成功,手术时间平均(98.0±9.0)min,排气时间平均(22.8±2.5)h。术后6 h下床活动并进水,24 h后进食;术后5~7 d痊愈出院,无胆漏等并发症发生。随访6~80个月,患者术前临床症状消失,无结石复发。术后6~12个月胆囊代偿性扩张,体积平均(30.29±4.23)cm3,较术前(21.72±4.34)cm3明显增大(t=-13.00,P0.001);术后胆囊收缩平均(56.9±10.9)%,较术前(48.5±12.7)%显著提高(t=-6.11,P0.001)。结论腹腔镜结合胆道镜行胆囊部分切除术治疗胆囊形态异常合并泥沙样结石性胆囊炎,对保护胆囊及胆囊功能具有重要意义,在严格掌握适应证的情况下有望成为手术保胆治疗的一种新术式。     

Original single-incision laparoscopic cholecystectomy for acute inflammation of the gallbladder

AIM: To investigate the safety and feasibility of our original single-incision laparoscopic cholecystectomy (SILC) for acute inflamed gallbladder (AIG).METHODS: One hundred and ten consecutive patients underwent original SILC for gallbladder disease without any selection criteria and 15 and 11 of these were diagnosed with acute cholecystitis and acute gallstone cholangitis, respectively. A retrospective review was performed not only between SILC for AIG and non-AIG, but also between SILC for AIG and traditional laparoscopic cholecystectomy (TLC) for AIG in the same period.RESULTS: Comparison between SILC for AIG and non-AIG revealed that the operative time was longer in SILC for AIG (97.5 min vs 85.0 min, P = 0.03). The open conversion rate (2/26 vs 2/84, P = 0.24) and complication rate (1/26 vs 3/84, P = 1.00) showed no differences, but a need for additional trocars was more frequent in SILC for AIG (5/24 vs 3/82, P = 0.01). Comparison between SILC for AIG and TLC for AIG revealed no differences based on statistical analysis.CONCLUSION: Our original SILC technique was adequately safe and feasible for the treatment of acute cholecystitis and acute gallstone cholangitis.     

腹腔镜下逆行全胆囊切除术与次全胆囊切除术治疗复杂胆管病变的效果比较

目的对比分析腹腔镜下逆行全胆囊切除术与腹腔下逆行次全胆囊切除术治疗复杂胆管病变的临床效果。方法收集2013年6月~(-2)015年3月广元市精神卫生中心诊治的83例胆管病变患者临床资料,其中40例行腹腔镜下逆行全胆囊切除术(A组),43例行腹腔镜下逆行次全胆囊切除术(B组),比较两组患者的手术过程及术后恢复情况。计量资料组间比较采用独立样本t检验,治疗前后组内比较采用配对t检验;计数资料组间比较采用χ~2检验。结果 B组患者手术时间、术中出血量、术中补液量、腹腔引流量均低于A组,差异均有统计学意义(t值分别为9.245、2.394、2.529、3.603,P值均0.05)。两组患者中转开腹率、胃肠道功能恢复时间、住院时间差异均无统计学意义(P值均0.05)。A组与B组患者术后1~3 d的体温、C反应蛋白测定值组间比较,差异均无统计学意义(P值均0.05);两组患者第2、3天体温、C反应蛋白测定值较术后第1天均降低(t值分别为3.184、3.402、3.151、3.390、3.497、5.184、3.916、6.024,P值均0.05)。B组患者术后并发症发生率低于A组,差异有统计学意义(2.33%vs20.00%,χ~2=6.696,P=0.010)。结论腹腔镜下逆行次全胆囊切除术治疗复杂胆管病变患者较腹腔镜下逆行全胆囊切除术具有缩短手术时间、减少术中出血、减少术后并发症等优势,值得临床推广。     

困难性腹腔镜胆囊切除术围手术期处理体会

目的探讨困难类型腹腔镜胆囊切除围手术期的处理方法及并发症的预防。方法利用回顾性分析临床资料的方法,选择广东省中山大学附属东华医院1999年-2013年10月82例因急性胆囊炎、Mirizzi综合征、腹部手术史伴腹腔严重粘连、萎缩性胆囊炎、合并肝硬化等困难类型腹腔镜胆囊切除术的临床资料,总结经验和教训。结果除6例中转开腹(占7.31%)外,余均用腹腔镜成功完成手术;术后胆道损伤、胆瘘2例,再次手术后治愈;术后出血4例,保守治疗后痊愈;术后不明原因、不同程度胆漏者10例,经引流后自愈。结论对于困难类型腹腔镜胆囊切除术,虽然手术操作难度大,风险高,只要围手术期处理方法适当,仍可以在腹腔镜下完成手术。     

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.     

老年人腹腔镜胆囊切除术521例临床分析

目的探讨腹腔镜胆囊切除在治疗老年人胆囊良性疾病中的应用价值。方法回顾性分析５２１例老年患者胆囊切除术的结果。结果５２１例中，单纯慢性结石性胆囊炎４５９例，其中继发胆总管结石２例，急性胆囊炎２４例，胆囊息肉３８例。术中因炎性粘连、疑胆囊癌等改做开腹手术１８例（３．５％），发生严重并发症３例（０．６％），治愈４９９例（９５．８％），死亡１例。结论为老年人施行腹腔镜胆囊切除术，如医生经过充分的训练并了解可能发生的困难，仍是安全可行的手术方法。     

腹腔镜胆囊切除术后早期切口疼痛的相关因素分析

正近年来腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)以其安全、创伤小、痛苦轻、对腹腔脏器干扰小、住院时间短、术后恢复快[1]、高危患者能耐受等特点,逐渐成为治疗胆囊良性疾患的首选方法。但术后早期出现切口疼痛仍是患者最多见的主诉症状,严重影响患者术后康复及生活质量[2]。传统的单一镇痛模式已经不能满足患者的镇痛效果,需要更多