腹腔镜下全子宫切除术的临床评估

目的：对腹腔腔镜下全宫切除的临床价值进行评估。方法：对４３ 例因诊断为子宫肌瘤（３３ 例） 、子宫腺肌症（６例） 及子宫内膜增殖症（４ 例） 的患者行腹腔镜下全子宫切除术,对同时期１２１ 例具有同样适应症的患者行腹式全子宫切除手术。比较两组病人术中术后情况。结果：两组病人的手术时间、术中出血量无显著性差异,腹腔镜下全子宫切除术的手术时间与子宫增大有关,术中出血量与手术时间及子宫大小无关;行腹腔镜下全子宫切除术的病人手术损伤及术后阴道残端出血发生率无增高,术后疼痛的发生率明显减少,术后使用抗菌素时间、术后住院时间及术后恢复正常活动的时间缩短。结论：腹腔镜下全子宫切除术虽不能完全代替腹式全宫切除术,却是一种安全、可靠,适于临床广泛开展的手术方式。     

Gallbladder torsion: case report and review of 245 cases reported in the Japanese literature

We report here a case of torsion of the gallbladder in a 73-year-old woman. The patient was admitted to our hospital with right hypochondralgia. Ultrasonography and computed tomography demonstrated a distended gallbladder, with a multilayered wall, which contained no stones. Since the symptoms did not respond to antibiotics, laparotomy was performed. The gallbladder was found to be twisted around its pedicle and to be gangrenous. Cholecystectomy was performed, and the patient had an uneventful postoperative course. We also reviewed 245 cases reported in the Japanese literature. The clinical features of gallbladder torsion, which include low frequency of fever and jaundice, poor response to antibiotic therapy, and acute onset of abdominal pain, may be helpful in the differential diagnosis from acute cholecystitis. Moreover, a highly suggestive sign of gallbladder torsion observed by ultrasonography or computed tomography is a markedly enlarged "floating" gallbladder with a continuous hypoechoic line indicating edematous change in the wall. Received for publication on Feb. 8, 1999; accepted on April 21, 1999     

Laparoscopic cholecystectomy in pregnancy

Background: Laparoscopic cholecystectomy is now the standard treatment for symptomatic gallstones; while symptomatic gallstones during pregnancy are not frequent they are by no means rare. The role of laparoscopic cholecystectomy during pregnancy is controversial but initial reports suggest it is both safe and feasible. Methods: During a consecutive series of 500 laparoscopic cholecystectomies, 3 patients have undergone laparoscopic cholecystectomy during pregnancy. The 3 patients were 16–27 weeks pregnant with an average age of 32 years. The indication for laparoscopic cholecystectomy was severe pain in two patients and gallstone pancreatitis in one patient. Following standard obstetric anesthesia, laparoscopic cholecystectomy was performed. Open cannulation was used to establish peritoneal access, following which standard, four-port laparoscopic cholecystectomy was performed without complication. The insufflation pressure used was 8–10 mmHg CO₂ and a liver retractor was employed to facilitate access. Results: In each case the postoperative recovery was rapid and uneventful for both mother and fetus. The patients were discharged on the first or second postoperative day. Conclusions: Laparoscopic cholecystectomy during the second trimester of pregnancy is both safe and feasible provided both suitable surgical and anesthetic expertise are available. Even up to the end of the second trimester there is sufficient access for the technique to be employed.     

Is male gender a risk factor for conversion of laparoscopic into open cholecystectomy?

Background: Based on a clinical observation that the conversion rate of laparoscopic cholecystectomy (LC) to open cholecystectomy (OC) is higher in males, we decided to review our records and to verify whether a significant difference in conversion rates exists between sexes. Methods: A retrospective study on conversion rates of elective laparoscopic cholecystectomy (LC) into open cholecystectomy (LC) in relation to gender was carried out in 329 patients: 267 females and 62 males. Results: Our data revealed that the probability of conversion is fivefold greater in males than females, 21% vs 4.5%, respectively (p=0.0001). We attribute this striking difference to significantly more adhesions (p=0.0002) and anatomical difficulties (p=0.003) in males during LC, leading to conversion. Conclusions: We conclude that conversion of LC to OC is more prevalent among males and is probably attributable to a greater incidence of anatomical difficulties.     

Why laparoscopic cholecystectomy today?

Traditional open cholecystectomy became the gold standard of surgical treatment for symptomatic gallstone disease during the last century. In spite of its good results, clinicians have been trying to establish effective nonsurgical methods of eliminating gallstones. Although oral, percutaneous, or retrograde litholysis can be used effectively for cholesterol stones, these represent only 10% of all gallstones. Moreover, intracorporeal lithotripsy is an invasive method, and while extracorporeal shock wave lithotripsy is a promising procedure, even after careful selection, only 70%–80% of the patients become stone-free within 1 year. In fact, none of the methods which leave the gallbladder intact are free of complications, and they are followed by 50% stone recurrence within 5 years. Since 1987, laparoscopic cholecystectomy has become the procedure of choice as it is safe and only minimally invasive. We believe that the laparoscopic technique is a promising way to the surgery of the future.     

Laparoscopic Assisted Surgery for Crohn''''s Disease an Initial Experience and Results

SurgicaltreatmentisoftenrequiredforpatientswithCrohn'sdiseasewhohaveintestinalstrictureand/orfistula[4.1o.13].Rapidevolutionoflaparoscopicintestinalsurgery,continuousadvancementofinstru-mentation,performanceofmoreextensiveandcom-p1exprocedureshaveledtotheapplicationoflaparo-scopictechniquesinthetreatmentofCrohn'sdis-ease[3'9'12J.Recentreportshavedemonstratedthat,comparedwithtraditional"open"resection,laparo-scopicintestinalsurgeryresultsindecreasedpostoper-ativepain,earlierreturnofintestinalf…     

腹腔镜腹部手术520例临床分析

目的探讨腹腔镜在腹部手术中的应用及并发症的预防。方法回顾性分析2001年3月～2005年3月腹腔镜下胆囊切除、阑尾切除、溃疡病穿孔修补、肠粘连松解、肝囊肿开窗、直肠癌前切术等520例临床资料。结果腹腔镜手术应用12种类，520例中有5例因胆囊三角解剖不清且胆囊萎缩而中转开腹手术，2例因术中出血而中转开腹。手术并发症3例（0．58％），其中胆管损伤2例。出血1例。结论腹腔镜手术的适应证随技术进步和设备改善将逐步拓宽；严格腹腔镜手术程序，严重并发症发生率可降低。     

Day-case laparoscopy: a comparison of prophylactic opioid, NSAID or local anesthesia for postoperative analgesia

BACKGROUND: The study was aimed to evaluate the analgesic efficacy, postoperative comfort, recovery characteristics and side effects of three different analgesic agents administered prophylactically. METHODS: Eighty patients undergoing day-case minor operative laparoscopy were randomly allocated into four groups to receive tenoxicam 20 mg i.v. (Group T), fentanyl 100 microg i.v. (Group F), 5 ml of bupivacaine 2.5 mg/ml for infiltration of trocar sites (Group B), 30, 10 and 5 min before incision respectively. Bupivacaine, 35 ml, 2.5 mg/ml was also administered into the pelvic cavity in Group B. Group P received only placebo. Postoperative pain, analgesic requirements, first response to verbal stimulus, first analgesic requirement, ability to walk without help, to drink and to void, blood pressures, SpO2 and respiration rates were recorded in the PACU. Postoperative pain was evaluated by verbal rating scale. Pain scores, analgesic requirements and side effects were evaluated by telephone calls until the 48th postoperative hour. RESULTS: Postoperative pain scores were lower and time to requirement of rescue analgesics was longer in groups F and B compared to Group P. In the PACU, analgesic requirements were lower in Group B, compared to Group P. Nausea and vomiting were increased in Group F. CONCLUSION: Tenoxicam 20 mg i.v. was found to be ineffective whereas bupivacaine was superior to other groups in reducing pain and analgesic requirements. Bupivacaine also increased time to first analgesics and obtained better recovery characteristics, underlining its value in prophylactic pain management compared to the other two agents.     

腹腔镜辅助下先天性巨结肠升结肠拖出根治术

目的 运用腹腔镜及超声刀技术对不能用经肛门拖出术式的小儿长段型巨结肠病例施行根治手术，充分发挥腹腔镜的微创手术优点，探讨其操作方法和特点。方法 对2000年6月至2001年11月收治的8例长段型先天性巨结肠患儿，使用腹腔镜及超声刀技术施行升结肠逆时针翻转拖出（Deloyers法）的先天性巨结肠根治术（改良Soave术）。观察手术过程、术中出血、术后合并症的出现、大便排出等情况。术后门诊随访。结果 8例手术均获成功，手术时间190－240min，平均218min。手术出血最多1例为20ml，余均少于5ml，无术后继发性出血，无术中和术后早期并发症。8例术后均在门诊复诊，随访3－20个月，所有患儿每日排便1－8次，无大便失禁或污粪。5例术后3个月大便稀糊状，半年后转成形大便。结论 应用腹腔镜超声刀技术可有效地施行升结肠拖出手术治疗长段型巨结肠，手术可弥补经肛门拖出手术和开腹手术的不足，近期效果良好。     

16例卵巢囊肿蒂扭转腹腔镜下保留卵巢手术治疗临床分析

目的：探讨卵巢囊肿蒂扭转患者行腹腔镜下保留卵巢手术的有效性及安全性。方法：16例卵巢囊肿蒂扭转患者采取腹腔镜下保留卵巢手术治疗,回顾性分析其效果。结果：术后3个月所有患者卵巢功能恢复正常,未见手术并发症。结论：卵巢囊肿蒂扭转患者行腹腔镜下保留卵巢手术安全有效,值得推广。