Kuidas on laparoskoopiline koletsüstektoomia

Laparoskoopiline koletsüstektoomia on muutunud küpseks kirurgiliseks tehnikaks, mida aktsepteerib enamik patsiente, kellel on vähem traumasid, vähem valu ja kiire taastumine.

(1) Näidustused

① Symptomatic gallstones.

② Symptomatic chronic cholecystitis.

③ Gallstone with diameter >3 cm.

④ Filled gallstones.

⑤ Symptomatic and surgically indicated protuberant lesions of the gallbladder.

⑥ The symptoms of acute cholecystitis were relieved after treatment, and there were surgical indications.

⑦ It is estimated that the patient is well tolerated.

(2) Suhtelised vastunäidustused

① Acute attack of calculous cholecystitis.

② Chronic atrophic calculous cholecystitis.

③ Secondary choledocholithiasis.

④ History of upper abdominal surgery.

⑤ Fat body.

⑥ External abdominal hernia.

(3) Absoluutne vastunäidustus

① Acute cholecystitis with serious complications, such as gallbladder empyema, gangrene, perforation, etc.

② Gallstone acute pancreatitis.

③ With acute cholangitis.

④ Primary common bile duct stones and intrahepatic bile duct stones.

⑤ Obstructive jaundice.

⑥ Gallbladder cancer.

⑦ Protuberant lesions of the gallbladder are suspected to be cancerous.

⑧ Cirrhosis and portal hypertension.

⑨ Middle and late pregnancy.

⑩ Abdominal infection, peritonitis.

Chronic atrophic cholecystitis, gallbladder less than 4.5cm × 1.5cm, wall thickness >0,5 cm (ultraheli mõõtmine).

Kaasnevad hemorraagilised haigused ja hüübimishäired.

Need, kellel on oluliste elundite funktsioon mittetäielikult, operatsiooni ja anesteesiat on raske taluda ning kellel on südamestimulaator (elektrokoagulatsioon ja elektrokauter on keelatud).

Üldine seisund on halb, ei sobi operatsiooniks või patsient on vana, puudub tugev koletsüstektoomia, diafragmaalsonga tunnus.

Laparoskoopilise kirurgia näidustuste ulatus laieneb koos tehnoloogia arenguga. Mõningaid haigusi, mis olid algselt operatsioonile vastunäidustused, on püütud lõpetada ka laparoskoopiaga. Kui sekundaarne sapikivitõbi on laparoskoopilise operatsiooniga osaliselt lahendatud. Pärast vajalike kogemuste omandamist saab laparoskoopilise operatsiooniga ravida rohkem haigusi.

(4) Kirurgiline protseduur

① Create pneumoperitoneum. Make an arc incision along the lower edge of the umbilical fossa, about 10mm long. If the lower abdomen has been operated on, cut the skin on the upper edge of the umbilical fossa to avoid the original surgical scar.

Operaator ja esimene assistent hoiavad kumbki käterätitange, et tõsta kõhuseina nabanööri mõlemalt küljelt. Operaator hoidis pneumoperitoneumi nõela (Veressi nõela) parema käe pöidla ja nimetissõrmega, avaldas jõudu randmele ja torkas kõhuõõnde vertikaalselt või veidi kaldu vaagnaõõnde.

Punktsiooni käigus, kui nõel murrab läbi fastsia ja kõhukelme, tekib kaks korda läbimurdetunne; Hinnake, kas nõela ots on sattunud kõhuõõnde. Võib ühendada tavalise soolalahusega süstla. Kui nõela ots on kõhuõõnes, näitab see negatiivset rõhku. Ühendage pneumoperitoneumi masin. Kui inflatsioonirõhk ei ületa 1,73 kpa, näitab see, et pneumoperitoneumi nõel on kõhuõõnes. Ärge pumbake alguses liiga kiiresti täis. Kasutage väikese vooluga täitmist, 1 2L minutis.

At the same time, observe the intraperitoneal pressure on the pneumoperitoneum machine. The pressure during inflation should not exceed 1.73kpa. If it is too high, it indicates that the position of the pneumoperitoneum needle is incorrect, the anesthesia is too shallow and the muscle is not loose enough. Appropriate adjustment should be made. When the abdomen begins to bulge and the liver dullness boundary disappears, it can be changed to high flow automatic inflation until the predetermined value (1.73 2.00kpa) is reached. At this time, the inflation is 3 4L, the patient's abdomen is completely bulged, and the operation can be started.

Lift the abdominal wall with towel pliers at the umbilical pneumoperitoneum needle and puncture with 10mm trocar. The first puncture has a certain "blindness", which is a more dangerous step in laparoscopy. Be extra careful. Rotate the trocar slowly and enter the needle evenly. When entering the abdominal cavity, there is a feeling that the resistance disappears suddenly. Open the closed air valve and gas escapes. This is the success of puncture. Connect the pneumoperitoneum machine to maintain constant pressure in the abdominal cavity. Then put the laparoscope in and puncture at each point under the monitoring of the laparoscope.

Üldiselt torgake 2 cm xiphoid protsessist allapoole ja asetage 10 mm ümbris tühjenduskonksu, klambriga aplikaatori ja muude instrumentide jaoks; Torgake 2 cm allapoole parema keskmise rangluu joone kaldaserva või 2 cm allapoole kõhusirglihase välisserva ja kaenlaaluse esiosa kaldaserva vastavalt 5 mm troakaariga, et panna irrigaatorisse ja sapipõie fikseeritud haaretangid. Praeguseks on kunstlik pneumoperitoneum ja ettevalmistused lõppenud.

Tänu pneumoperitoneumi valmistamisele ja esimesele trokaari punktsioonile võivad kogemata vigastada kõhuõõne suured veresooned ja sooled, mida pole operatsiooni käigus lihtne leida. Hiljuti on paljud inimesed teinud kõhukelme leidmiseks nabasse väikese ava ja pannud trokaari otse kõhuõõnde täispuhumiseks. Pärast pneumoperitoneumi edukat valmistamist alustati operatsiooniga.

② Dissect the Calot triangle. Grasp the neck of gallbladder or Hartmann's bursa with grasping forceps and traction to the upper right. It is best to draw the cystic duct perpendicular to the common bile duct in order to clearly distinguish the two, but pay attention not to draw the common bile duct into an angle. The serous membrane on the cystic duct was cut with an electrocoagulation hook, the cystic duct and cystic artery were passively separated, and the common bile duct and common hepatic duct were distinguished. Since it is close to the common bile duct, electrocoagulation should be used as little as possible to avoid accidental injury to the common bile duct. Use the electrocoagulation hook to separate the cystic duct upstream and downstream, and see the relationship between the cystic duct and the common bile duct. Place the titanium clip as close to the gallbladder neck as possible. There should be sufficient distance between the two titanium clips. The titanium clip should be at least 0.5cm away from the common bile duct. Cut between the two titanium clips with scissors, and do not use electric cutting or electrocoagulation to prevent damage to the common bile duct due to heat conduction. Then find the cystic artery behind it and cut it with titanium clip. After cutting off the gallbladder artery, do not pull hard to avoid breaking the gallbladder artery, and pay attention to the posterior branch of the gallbladder. Carefully peel off the gallbladder, electrocoagulation or hemostasis with titanium clip.

③ Cholecystectomy. Clamp the gallbladder neck and pull it upward, carefully peel it off along the gallbladder wall, and the assistant should assist in pulling to make the gallbladder and liver bed have a certain tension. Completely peel off the gallbladder and place it on the upper right side of the liver. The liver bed was hemostatic by electrocoagulation, carefully rinsed with normal saline, and checked for bleeding and bile leakage (a piece of gauze was disposed at the hepatic hilum, and checked for bile staining after removal). After absorbing all the water in the abdominal cavity, transfer the laparoscope to the lower sleeve of the xiphoid process and give way to the umbilical incision, so that the gallbladder containing stones greater than 1cm can be taken out from the umbilical incision with loose structure and easy expansion. If the stones are small, they can also be taken out from the puncture hole under the xiphoid process.

④ Remove the gallbladder. Put the toothed claw forceps into the abdominal cavity from the cannula at the umbilicus, grasp the residual end of the cystic duct under monitoring, slowly drag the gallbladder into the cannula sheath and pull it out together with the cannula sheath. When grasping the gallbladder, pay attention to placing the gallbladder on the liver to avoid accidental injury to the intestinal canal by sharp forceps. If the stone is large or the tension of the gallbladder is high, do not pull it out with force to avoid rupture of the gallbladder and leakage of stones and bile into the abdominal cavity. At this time, the incision can be enlarged with vascular forceps and taken out, or the incision can be expanded to 2.0cm with an expander. If the stone is too large, the incision can be extended. If bile leaks into the abdominal cavity, wet gauze shall be used to enter from the umbilical incision to suck up the bile.

Kui kivi on sisselõikelt eemaldamiseks liiga suur, võib enne avada ka sapipõie, imeda aspiraatoriga sapipõies olev sapp ja pärast kivi tangidega purustamist ükshaaval välja võtta. Kui avastatakse, et kivi kukub kõhuõõnde, võtke see välja. Pärast kontrollimist, et kõhuõõnes ei ole verd ja vedelikku, tõmmake laparoskoop välja, avage kanüüli klapp, et väljutada kõhuõõnde süsihappegaas, ja seejärel tõmmake kanüül välja. 10 mm kanüüliga sisselõige õmmeldakse õhukese niidiga sidekihina 1 2 õmbluseks ja iga sisselõige suletakse steriilse kleepuva kilega.

(5) Suured tüsistused

① Bile duct injury. Bile duct injury is one of the most common and serious complications of laparoscopic cholecystectomy.

Sapiteede vigastuste ja sapi lekke esinemissagedus on umbes 10 protsenti. Sellele tuleks pöörata piisavalt tähelepanu. See on peamiselt tingitud Caloti kolmnurga ebaselgest anatoomiast, eriti valvsuse puudumisest tavalise sapijuha või tsüstilise kanali tavalise variatsiooni vastu. Tsüstilise kanali eraldamisel sai sapijuha tahtmatult termiliselt kahjustatud, operatsiooni ajal sapi lekkimist ei esinenud, samuti võis sapi lekkimist põhjustada operatsioonijärgne nekroos ja koe mahakukkumine termiliselt kahjustatud piirkonnas. Lisaks on sageli sapipõie voodis suured vagaalsed sapijuhad. Intraoperatiivne elektrokoagulatsioon ei saa täielikult koaguleeruda, samuti võib tekkida sapi leke. Sapiteede vigastuse peamised ilmingud on tugev ülakõhuvalu, kõrge palavik ja kollatõbi. Tüüpiliste ilmingutega patsiente ravitakse tavaliselt õigeaegselt pärast operatsiooni; Kuid mõnel patsiendil ilmnes ainult kõhu turse, isutus, madal palavik ja progresseeruv ägenemine. Selliseid patsiente tuleb hoolikalt jälgida. Teatati, et mõni kuu pärast operatsiooni avastati intraabdominaalne sapi kogunemine. Sapi lekke üle otsustamine sõltub peamiselt ultrahelist või CT-st ja seejärel peene nõela punktsioonist ultraheli või CT või radionukliidide hepatokolangiograafia juhtimisel.

② Vascular injury. One is massive hemorrhage caused by needle tip injury to abdominal aorta, iliac artery or mesenteric vessels during pneumoperitoneum and trocar placement. There are many reports of death caused by trocar puncture. Therefore, after successful pneumoperitoneum, laparoscopy should peep the whole abdomen once to prevent missing vascular injury.

Teine on maksavärava ebaselge anatoomia või parema maksaarteri või õige maksaarteri vale kinnitus sapipõiearteri verejooksu tõttu. Samuti on teateid portaalveeni vigastustest anatoomia ajal. On teatatud parema maksa nekroosist, mis on põhjustatud maksaarteri valest kinnitusest.

③ Intestinal injury. Intestinal injuries are mostly accidental injuries caused by electrocoagulation, mainly because the electrocoagulation hook is not placed in the TV monitoring picture and is not found. Abdominal pain, abdominal distention and fever occur after operation, resulting in serious peritonitis, and its mortality is high.

④ Postoperative intraperitoneal hemorrhage. Postoperative intraperitoneal hemorrhage is also one of the serious complications of laparoscopic surgery. The injured parts are mainly the blood vessels near the gallbladder, such as hepatic artery, portal vein and abdominal aorta or vena cava during periumbilical puncture. The manifestations were hemorrhagic shock, abdominal bulge and peripheral circulatory failure. Open surgery should be performed immediately to stop bleeding.

⑤ Subcutaneous emphysema. The causes of subcutaneous emphysema are as follows: first, when making pneumoperitoneum, the pneumoperitoneum needle did not penetrate the abdominal wall, and high-pressure carbon dioxide entered the subcutaneous; Second, due to the small skin incision, the trocar is embedded very tightly, and the puncture hole of the peritoneum is relatively loose. During the operation, carbon dioxide gas leaks into the lower skin layer of the abdominal wall. Postoperative examination can find abdominal subcutaneous twisting pronunciation, generally without special treatment.

⑥ Others. Such as incisional hernia, incisional infection and abdominal abscess.