Sut Mae Cholecystectomi Laparosgopig

Mae colecystectomi laparosgopig wedi dod yn dechneg lawfeddygol aeddfed, a dderbynnir gan y mwyafrif o gleifion â nodweddion llai o drawma, llai o boen ac adferiad cyflym.

(1) Arwyddion

① Symptomatic gallstones.

② Symptomatic chronic cholecystitis.

③ Gallstone with diameter >3cm.

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) Gwrtharwyddion cymharol

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) Gwrtharwyddion absoliwt

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 (mesuriad ultrasonic).

Ynghyd â chlefydau hemorrhagic a chamweithrediad ceulo.

Y rhai sydd â swyddogaeth anghyflawn organau pwysig, sy'n anodd eu goddef llawdriniaeth ac anesthesia, a'r rhai â rheoliadur cardiaidd (gwaherddir electrocoagulation ac electrocautery).

Mae'r cyflwr cyffredinol yn wael, nid yw'n addas ar gyfer llawdriniaeth neu mae'r claf yn hen, nid oes unrhyw arwydd cryf o colecystectomi, torgest diaffragmatig.

Mae cwmpas yr arwyddion ar gyfer llawdriniaeth laparosgopig yn ehangu gyda datblygiad technoleg. Mae laparosgopi hefyd wedi ceisio cwblhau rhai clefydau a oedd yn wrtharwyddion i lawdriniaeth yn wreiddiol. Os yw'r coledocholithiasis uwchradd wedi'i ddatrys yn rhannol trwy lawdriniaeth laparosgopig. Ar ôl cael y profiad angenrheidiol, gellir trin mwy o afiechydon trwy lawdriniaeth laparosgopig.

(4) Gweithdrefn lawfeddygol

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.

Mae'r gweithredwr a'r cynorthwyydd cyntaf bob un yn dal gefail tywelion brethyn i godi wal yr abdomen o ddwy ochr y fossa bogail. Daliodd y gweithredwr y nodwydd pneumoperitoneum (Nodyn Veress) â bawd a mynegfys ei law dde, rhoddodd rym ar ei arddwrn, a thrywanodd i mewn i geudod yr abdomen yn fertigol neu ychydig yn lletraws i mewn i geudod y pelfis.

Yn y broses o dyllu, pan fydd y nodwydd yn torri trwy'r ffasgia a'r peritonewm, mae ymdeimlad o dorri tir newydd ddwywaith; Barnwch a yw blaen y nodwydd wedi mynd i mewn i geudod yr abdomen. Gellir cysylltu chwistrell gyda saline arferol. Pan fydd blaen y nodwydd yn y ceudod abdomenol, mae'n dangos pwysau negyddol. Cysylltwch y peiriant niwmoperitonewm. Os nad yw'r pwysedd chwyddiant yn fwy na 1.73kpa, mae'n nodi bod y nodwydd pneumoperitoneum yn y ceudod abdomenol. Peidiwch â chwyddo'n rhy gyflym ar y dechrau. Defnyddiwch chwyddiant llif isel, 1 2L y funud.

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.

Yn gyffredinol, tyllu 2cm o dan y broses xiphoid a rhoi casin 10mm ar gyfer bachyn rhyddhau, taenwr clamp ac offerynnau eraill; Tyllu 2cm o dan ymyl arfordirol y llinell ganol dde clavicular neu 2cm islaw ymyl allanol rectus abdominis ac ymyl arfordirol y blaen echelinol gyda throcar 5mm yn y drefn honno i roi yn y dyfrhau a'r gallbladder gefeiliau gafael sefydlog. Ar yr adeg hon, mae niwmoperitonewm artiffisial a pharatoadau wedi'u cwblhau.

Oherwydd gweithgynhyrchu pneumoperitoneum a'r twll trocar cyntaf, gall y pibellau gwaed mawr a'r coluddion yn y ceudod abdomenol gael eu hanafu'n ddamweiniol, ac nid yw'n hawdd dod o hyd iddo yn ystod y llawdriniaeth. Yn ddiweddar, mae llawer o bobl wedi gwneud agoriad bach yn yr umbilicus i ddod o hyd i'r peritonewm a rhoi'r trocar yn uniongyrchol i'r ceudod abdomenol ar gyfer chwyddiant. Ar ôl cynhyrchu pneumoperitoneum yn llwyddiannus, dechreuwyd y llawdriniaeth.

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.

Os yw'r garreg yn rhy fawr i'w thynnu o'r toriad, gallwch hefyd agor y goden fustl yn gyntaf, sugno'r bustl yn y goden fustl gyda anadlydd, a'i thynnu allan fesul un ar ôl malu'r garreg â gefeiliau. Os canfyddir bod carreg yn disgyn i geudod yr abdomen, tynnwch hi allan. Ar ôl gwirio nad oes gwaed a hylif yn y ceudod abdomenol, tynnwch y laparosgop allan, agorwch falf y canwla i ollwng y nwy carbon deuocsid yn y ceudod abdomenol, ac yna tynnwch y canwla allan. Mae'r toriad â chanwla 10mm wedi'i bwytho ag edau denau fel haen ffasgia ar gyfer 1 2 pwyth, ac mae pob toriad wedi'i gau â ffilm gludiog di-haint.

(5) Cymhlethdodau mawr

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

Mae nifer yr achosion o anafiadau dwythell y bustl a gollyngiad bustl tua 10 y cant. Dylid talu digon o sylw iddo. Mae'n bennaf oherwydd anatomeg aneglur triongl Calot, yn enwedig y diffyg gwyliadwriaeth yn erbyn yr amrywiad cyffredin o ddwythell bustl gyffredin neu ddwythell systig. Wrth wahanu'r ddwythell systig, cafodd dwythell y bustl ei niweidio'n thermol yn anfwriadol, nid oedd unrhyw ollyngiad bustl yn ystod y llawdriniaeth, a gallai necrosis a chwympo'r meinwe yn yr ardal a ddifrodwyd yn thermol ar ôl y llawdriniaeth hefyd achosi gollyngiad bustl. Yn ogystal, yn aml mae dwythellau bustl vagal mawr yn y gwely goden fustl. Ni all electroceulad mewnlawdriniaethol geulo'n llwyr, a gellir ffurfio gollyngiad bustl hefyd. Y prif amlygiadau o anaf dwythell y bustl yw poen difrifol yn rhan uchaf yr abdomen, twymyn uchel a chlefyd melyn. Mae cleifion ag amlygiadau nodweddiadol fel arfer yn cael eu trin mewn pryd ar ôl llawdriniaeth; Fodd bynnag, dim ond diffyg yn yr abdomen a ddangosodd rhai cleifion, diffyg archwaeth, twymyn isel a gwaethygu cynyddol. Dylid arsylwi cleifion o'r fath yn agos. Dywedwyd bod bustl yn cronni o fewn yr abdomen wedi'i ganfod ychydig fisoedd ar ôl llawdriniaeth. Mae barnu a oes gollyngiad bustl yn dibynnu'n bennaf ar uwchsain neu CT, ac yna'n cael ei gadarnhau gan dyllu nodwydd fain dan arweiniad uwchsain neu CT neu hepatocholangiography radioniwclid.

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.

Y llall yw anatomeg aneglur y porth hepatig neu glampio anghywir y rhydweli hepatig cywir neu'r rhydweli hepatig iawn oherwydd gwaedu rhydweli goden fustl. Mae adroddiadau hefyd o anaf i wythïen borthol yn ystod anatomeg. Cafwyd adroddiadau o necrosis hepatig cywir a achosir gan glampio anghywir o rydweli hepatig.

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.