Kif Inhi Kolekistektomija Laparoskopika

Kolekistektomija laparoskopika saret teknika kirurġika matura, li hija aċċettata mill-maġġoranza tal-pazjenti bil-karatteristiċi ta 'inqas trawma, inqas uġigħ u rkupru rapidu.

(1) Indikazzjonijiet

① Symptomatic gallstones.

② Symptomatic chronic cholecystitis.

③ Gallstone with diameter >3ċm.

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) Kontra-indikazzjonijiet relattivi

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) Kontra-indikazzjoni assoluta

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 >0.5cm (kejl ultrasoniku).

Akkumpanjat minn mard emorraġiku u disfunzjoni tal-koagulazzjoni.

Dawk b'funzjoni mhux kompluta ta 'organi importanti, diffiċli biex jittolleraw operazzjoni u anestesija, u dawk b'pacemaker kardijaku (elettrokoagulazzjoni u electrocautery huma pprojbiti).

Il-kundizzjoni ġenerali hija fqira, mhix adattata għall-operazzjoni jew il-pazjent huwa antik, m'hemm l-ebda indikazzjoni qawwija ta 'kolekistektomija, ftuq dijaframmatiku.

L-ambitu tal-indikazzjonijiet għall-kirurġija laparoskopika qed jespandi bl-iżvilupp tat-teknoloġija. Xi mard li oriġinarjament kien kontra-indikazzjonijiet għall-kirurġija ġew ippruvati wkoll biex jitlestew bil-laparoskopija. Jekk il-koledokolitjażi sekondarja ġiet solvuta parzjalment b'kirurġija laparoskopika. Wara li tinkiseb l-esperjenza meħtieġa, aktar mard jista 'jiġi ttrattat permezz ta' kirurġija laparoskopika.

(4) Proċedura kirurġika

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.

L-operatur u l-ewwel assistent kull wieħed iżomm tnalji tax-xugaman tad-drapp biex jerfgħu l-ħajt addominali miż-żewġ naħat tal-fossa umbilikali. L-operatur żamm il-labra tal-pnewmoperitoneum (labra Veress) bis-saba 'l-kbir u l-indiċi ta' idu l-leminija, eżerċita forza fuq il-polz tiegħu, u daħal fil-kavità addominali vertikalment jew ftit oblikwu fil-kavità pelvika.

Fil-proċess ta 'titqib, meta l-labra tkisser mill-fascia u l-peritoneum, hemm sens ta' breakthrough darbtejn; Iġġudika jekk il-ponta tal-labra tkunx daħlet fil-kavità addominali. Tista' titqabbad siringa b'salina normali. Meta l-ponta tal-labra tkun fil-kavità addominali, turi pressjoni negattiva. Qabbad il-magna tal-pnewmoperitoneum. Jekk il-pressjoni tal-inflazzjoni ma taqbiżx 1.73kpa, tindika li l-labra tal-pnewmoperitoneum tinsab fil-kavità addominali. Tinflaħx malajr wisq fil-bidu. Uża inflazzjoni ta 'fluss baxx, 1 2L kull minuta.

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.

Ġeneralment, ittaqqab 2cm taħt il-proċess ta 'xiphoid u poġġi casing ta' 10mm għal ganċ ta 'discharge, applikatur tal-morsa u strumenti oħra; Ittaqqab 2cm taħt it-tarf kostali tal-linja tan-nofs tal-lemin tal-klavikulari jew 2cm taħt it-tarf ta 'barra tar-rectus abdominis u t-tarf kostali tal-faċċata axillari b'trokar ta' 5mm rispettivament biex tpoġġi fil-irrigator u l-marrara fiss ta 'grabping forceps. F'dan iż-żmien, pnewmoperitoneum artifiċjali u preparazzjonijiet tlestew.

Minħabba l-manifattura tal-pnewmoperitoneum u l-ewwel titqib tat-trokar, il-vini u l-imsaren kbar fil-kavità addominali jistgħu jiġu mweġġa 'aċċidentalment, u mhuwiex faċli li ssib waqt l-operazzjoni. Riċentement, ħafna nies għamlu ftuħ żgħir fiż-żokra biex isibu l-peritoneum u jpoġġu direttament it-trokar fil-kavità addominali għall-inflazzjoni. Wara l-manifattura b'suċċess tal-pnewmoperitoneum, inbdiet l-operazzjoni.

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.

Jekk il-ġebla hija kbira wisq biex titneħħa mill-inċiżjoni, tista 'wkoll tiftaħ il-marrara l-ewwel, terda' l-bili fil-marrara b'aspiratur, u oħroġha waħda waħda wara li tfarrak il-ġebla bil-forceps. Jekk ġebel jinstab li taqa 'fil-kavità addominali, oħroġ. Wara li ċċekkja li m'hemm l-ebda demm u likwidu fil-kavità addominali, iġbed il-laparoscope, iftaħ il-valv tal-kannula biex tarmi l-gass tad-dijossidu tal-karbonju fil-kavità addominali, u mbagħad iġbed il-kannula. L-inċiżjoni b'kannula ta '10mm hija suturata b'ħajt irqiq bħala saff fascia għal 1 2 ponti, u kull inċiżjoni hija magħluqa b'film adeżiv sterili.

(5) Kumplikazzjonijiet kbar

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

L-inċidenza ta 'korriment fil-kanal tal-bili u t-tnixxija tal-bili hija ta' madwar 10 fil-mija. Għandha tingħata attenzjoni biżżejjed. Huwa prinċipalment minħabba l-anatomija mhux ċara tat-trijangolu Calot, speċjalment in-nuqqas ta 'viġilanza kontra l-varjazzjoni komuni tal-kanal tal-bili komuni jew tal-kanal ċstiku. Meta tissepara l-kanal ċistika, il-kanal tal-bili kien involontarjament bil-ħsara termikament, ma kien hemm l-ebda tnixxija tal-bili matul l-operazzjoni, u n-nekrożi u l-waqgħa mit-tessut fiż-żona bil-ħsara termikament wara l-operazzjoni jistgħu wkoll jikkawżaw tnixxija tal-bili. Barra minn hekk, ħafna drabi jkun hemm kanali tal-bili vagali kbar fis-sodda tal-marrara. L-elettrokoagulazzjoni intraoperattiva ma tistax tikkoagula kompletament, u t-tnixxija tal-bili tista 'wkoll tiġi ffurmata. Il-manifestazzjonijiet ewlenin ta 'korriment fil-kanal tal-bili huma uġigħ sever fl-addome ta' fuq, deni għoli u suffejra. Pazjenti b'manifestazzjonijiet tipiċi huma ġeneralment ittrattati fil-ħin wara l-operazzjoni; Madankollu, ftit pazjenti wrew biss distensjoni addominali, nuqqas ta 'aptit, deni baxx u aggravament progressiv. Pazjenti bħal dawn għandhom jiġu osservati mill-qrib. Ġie rrappurtat li l-akkumulazzjoni tal-bili intraaddominali nstabet ftit xhur wara l-operazzjoni. Biex tiġġudika jekk hemmx tnixxija tal-bili tiddependi prinċipalment fuq ultrasound jew CT, u mbagħad ikkonfermat minn titqib tal-labra fina taħt il-gwida ta 'ultrasound jew CT jew epatocholangiography radjonuklidi.

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.

L-ieħor huwa l-anatomija mhux ċara tal-portal epatiku jew l-ikklampjar ħażin tal-arterja epatika t-tajba jew l-arterja epatika xierqa minħabba fsada tal-arterja tal-marrara. Hemm ukoll rapporti ta 'ferita fil-vini portali waqt l-anatomija. Kien hemm rapporti ta' nekrożi epatika tal-lemin ikkawżata minn kklampjar ħażin tal-arterja epatika.

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.