Kako je laparoskopska kolecistektomija

Laparoskopska kolecistektomija postala je zrela kirurška tehnika koju prihvaća većina pacijenata s obilježjima manje traume, manje boli i brzog oporavka.

(1) Indikacije

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) Relativne kontraindikacije

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) Apsolutna kontraindikacija

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 (ultrazvučno mjerenje).

U pratnji hemoragijskih bolesti i poremećaja koagulacije.

Oni s nepotpunom funkcijom važnih organa, teško podnošljivim operacijama i anestezijom te onima s srčanim pacemakerom (zabranjeni su elektrokoagulacija i elektrokauterizacija).

Opće stanje je loše, nije pogodno za operaciju ili je bolesnik star, nema jakih naznaka kolecistektomije, dijafragmalne kile.

Razvojem tehnologije širi se opseg indikacija za laparoskopsku kirurgiju. Neke bolesti koje su prvotno bile kontraindikacije za operaciju pokušale su se dovršiti i laparoskopijom. Ako je sekundarna koledoholitijaza djelomično riješena laparoskopskom operacijom. Nakon stjecanja potrebnog iskustva, više bolesti može se liječiti laparoskopskom operacijom.

(4) Kirurški zahvat

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.

Operater i prvi pomoćnik drže kliješta za ručnike od tkanine kako bi podigli trbušnu stijenku s obje strane pupčane jame. Operater je palcem i kažiprstom desne ruke držao iglu za pneumoperitoneum (Veressova igla), izvršio silu na zapešće i zabadao u trbušnu šupljinu okomito ili blago koso u zdjeličnu šupljinu.

U procesu punkcije, kada se igla probije kroz fasciju i peritoneum, dvaput se javlja osjećaj probijanja; Procijenite je li vrh igle ušao u trbušnu šupljinu. Može se spojiti štrcaljka s normalnom fiziološkom otopinom. Kada je vrh igle u trbušnoj šupljini, pokazuje negativan tlak. Spojite pneumperitoneum stroj. Ako tlak napuhavanja ne prelazi 1,73 kpa, to znači da je igla pneumoperitoneuma u trbušnoj šupljini. Nemojte napuhavati prebrzo na početku. Koristite napuhavanje malog protoka, 1 2L u minuti.

Istodobno promatrajte intraperitonealni pritisak na pneumperitoneumskom stroju. Tlak tijekom napuhavanja ne smije prelaziti 1,73 kpa. Ako je previsok, to znači da je položaj igle pneumoperitoneuma pogrešan, da je anestezija preplitka i da mišić nije dovoljno labav. Potrebno je izvršiti odgovarajuću prilagodbu. Kada se trbuh počne izbočiti i granica tuposti jetre nestane, može se promijeniti na automatsko napuhavanje visokog protoka dok se ne postigne unaprijed određena vrijednost (1,73 2.00kpa). U ovom trenutku napuhavanje je 3 4L, pacijentov trbuh je potpuno ispupčen i može se pristupiti operaciji.

Podignite trbušnu stijenku kliještima za ručnike na umbilikalni pneumperitoneum iglu i probušite trokarom od 10 mm. Prva punkcija ima određenu "sljepoću", što je opasniji korak u laparoskopiji. Budite posebno oprezni. Polako rotirajte trokar i ravnomjerno uđite u iglu. Prilikom ulaska u trbušnu šupljinu javlja se osjećaj da otpor naglo nestaje. Otvorite zatvoreni ventil za zrak i plin izlazi. To je uspjeh punkcije. Spojite pneumoperitoneum stroj za održavanje konstantnog tlaka u trbušnoj šupljini. Zatim stavite laparoskop i probušite na svakoj točki pod nadzorom laparoskopa.

Općenito, probušite 2 cm ispod xiphoidnog nastavka i stavite kućište od 10 mm za kuku za pražnjenje, aplikator stezaljke i druge instrumente; Probušite 2 cm ispod obalnog ruba desne srednje klavikularne linije ili 2 cm ispod vanjskog ruba rectus abdominisa i obalnog ruba aksilarne prednje strane trokarom od 5 mm kako bi se umetnule hvataljke za irigator i žučni mjehur. U ovom trenutku je završen umjetni pneumperitoneum i pripreme.

Zbog izrade pneumoperitoneuma i prve punkcije trokara mogu se slučajno ozlijediti velike krvne žile i crijeva u trbušnoj šupljini, a to nije lako pronaći tijekom operacije. Nedavno su mnogi ljudi napravili mali otvor na pupku kako bi pronašli peritoneum i izravno stavili trokar u trbušnu šupljinu radi napuhavanja. Nakon uspješne izrade pneumperitoneuma pristupilo se operaciji.

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.

Ako je kamen prevelik da bi se mogao izvaditi iz reza, također možete prvo otvoriti žučni mjehur, usisati žuč u žučnom mjehuru aspiratorom i vaditi je jednu po jednu nakon što zdrobite kamen pincetom. Ako se utvrdi da kamen pada u trbušnu šupljinu, izvadite ga. Nakon što provjerite da u trbušnoj šupljini nema krvi i tekućine, izvucite laparoskop, otvorite ventil kanile kako biste ispustili plin ugljični dioksid u trbušnu šupljinu, a zatim izvucite kanilu. Rez s kanilom od 10 mm šiva se tankim koncem kao slojem fascije za 1 2 šava, a svaki rez se zatvara sterilnom ljepljivom folijom.

(5) Velike komplikacije

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

Učestalost ozljeda žučnih vodova i istjecanja žuči je oko 10 posto . Treba joj posvetiti dovoljno pažnje. To je uglavnom zbog nejasne anatomije Calotovog trokuta, posebno nedostatka budnosti protiv uobičajene varijacije zajedničkog žučnog kanala ili cističnog kanala. Prilikom odvajanja cističnog kanala došlo je do nenamjernog termičkog oštećenja žučnog kanala, tijekom operacije nije došlo do istjecanja žuči, a nekroza i otpadanje tkiva u termički oštećenom području nakon operacije također može uzrokovati istjecanje žuči. Osim toga, često se u krevetu žučnog mjehura nalaze veliki žučni kanali vagusa. Intraoperativna elektrokoagulacija ne može u potpunosti koagulirati, a može doći i do curenja žuči. Glavne manifestacije ozljede žučnih vodova su jaka bol u gornjem dijelu trbuha, visoka temperatura i žutica. Bolesnici s tipičnim manifestacijama obično se liječe na vrijeme nakon operacije; Međutim, nekoliko pacijenata pokazalo je samo nadutost trbuha, nedostatak apetita, nisku temperaturu i progresivno pogoršanje. Takve bolesnike treba pomno promatrati. Prijavljeno je da je intraabdominalno nakupljanje žuči pronađeno nekoliko mjeseci nakon operacije. Procijeniti postoji li curenje žuči uglavnom ovisi o ultrazvuku ili CT-u, a zatim se potvrđuje ubodom finom iglom pod vodstvom ultrazvuka ili CT ili radionuklidne hepatoholangiografije.

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.

Druga je nejasna anatomija jetrenog portala ili pogrešno stezanje desne jetrene arterije ili pravilne jetrene arterije zbog krvarenja arterije žučnog mjehura. Također postoje izvješća o ozljedi portalne vene tijekom anatomije. Bilo je izvješća o nekrozi desne jetre uzrokovanoj pogrešnim stezanjem jetrene arterije.

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.