Kako je laparoskopska holecistektomija

Laparoskopska kolecistektomija je postala zrela hirurška tehnika koju prihvata većina pacijenata sa karakteristikama manje traume, manje boli i brzog oporavka.

(1) Indikacije

① Symptomatic gallstones.

② Symptomatic chronic cholecystitis.

③ Gallstone with diameter gt; 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) 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.

Hronični atrofični holecistitis, žučna kesa manja od 4,5cm 1,5cm, debljina zida gt; 0.5 cm (ultrazvučno mjerenje).

Prate ga hemoragijska oboljenja i poremećaj koagulacije.

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

Opšte stanje je loše, nije pogodno za operaciju ili je pacijent star, nema jakih indikacija holecistektomije, dijafragmalne kile.

Razvojem tehnologije širi se opseg indikacija za laparoskopsku hirurgiju. Neke bolesti koje su prvobitno bile kontraindikacije za operaciju pokušale su se upotpuniti i laparoskopijom. Ako je sekundarna holedoholitijaza djelimično riješena laparoskopskom operacijom. Nakon stjecanja potrebnog iskustva, više bolesti može se liječiti laparoskopskom operacijom.

(4) Hirurški 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 svaki drže klešta za peškire za podizanje trbušnog zida sa obe strane pupčane jame. Operater je palcem i kažiprstom desne ruke držao iglu za pneumoperitoneum (Veressovu iglu), izvršio silu na zglob i zabadao je u trbušnu šupljinu okomito ili blago koso u karličnu šupljinu.

U procesu punkcije, kada se igla probije kroz fasciju i peritoneum, dvaput se javlja osjećaj probijanja; Procijenite da li je vrh igle ušao u trbušnu šupljinu. Može se priključiti špric sa normalnim fiziološkim rastvorom. Kada je vrh igle u trbušnoj šupljini, pokazuje negativan pritisak. Priključite pneumoperitoneum mašinu. Ako pritisak naduvavanja ne prelazi 1,73 kpa, to znači da je pneumperitoneumska igla u trbušnoj šupljini. Nemojte naduvati prebrzo na početku. Koristite naduvavanje malog protoka, 1 2L u minuti.

Istovremeno, posmatrajte intraperitonealni pritisak na pneumperitoneum mašini. Pritisak tokom naduvavanja ne bi trebalo da prelazi 1,73 kpa. Ako je previsok, to ukazuje da je položaj igle pneumperitoneuma nepravilan, da je anestezija preplitka i da mišić nije dovoljno labav. Potrebno je izvršiti odgovarajuću prilagodbu. Kada abdomen počne da se izboči i granica zatupljenosti jetre nestane, može se promijeniti na automatsko naduvavanje visokog protoka dok se ne dostigne unaprijed određena vrijednost (1,73 2.00kpa). U ovom trenutku naduvavanje je 3 4L, pacijentov abdomen je potpuno ispupčen i može se pristupiti operaciji.

Podignite trbušni zid kliještima za peškire na igli pupčane pneumoperitoneuma 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 vazduh i gas izlazi. To je uspjeh punkcije. Priključite pneumoperitoneum aparat za održavanje konstantnog pritiska u trbušnoj šupljini. Zatim stavite laparoskop i probušite na svakoj tački 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 2cm ispod obalnog ruba desne srednje klavikularne linije ili 2cm ispod vanjskog ruba rectus abdominisa i obalnog ruba aksilarnog prednjeg dijela trokarom od 5 mm, odnosno stavite u irigator i fiksirane hvataljke za žučnu kesu. U ovom trenutku je završen vještački pneumperitoneum i pripreme.

Zbog izrade pneumoperitoneuma i prve punkcije trokara mogu se slučajno ozlijediti veliki krvni sudovi i crijeva u trbušnoj šupljini, a to nije lako pronaći tokom operacije. Nedavno su mnogi ljudi napravili mali otvor na pupku kako bi pronašli peritoneum i direktno ubacili trokar u trbušnu šupljinu radi naduvavanja. Nakon uspješne izrade pneumperitoneuma, pristupilo se operaciji.

② Dissect the Calot triangle. Grasp the neck of gallbladder or Hartmann39;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 ukloniti iz reza, možete prvo otvoriti žučnu kesu, usisati žuč u žučnoj kesi aspiratorom i izvaditi je jednu po jednu nakon što zdrobite kamen pincetom. Ako se utvrdi da kamen pada u trbušnu šupljinu, izvadite ga. Nakon što provjerite da nema krvi i tekućine u trbušnoj šupljini, izvucite laparoskop, otvorite ventil kanile kako biste ispustili plin ugljični dioksid u trbušnu šupljinu, a zatim izvucite kanilu. Rez sa kanilom od 10 mm se šije tankim koncem kao sloj fascije za 1 2 šava, a svaki rez se zatvara sterilnom lepljivom folijom.

(5) Velike komplikacije

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

Incidencija ozljeda žučnih kanala i curenja 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, tokom operacije nije došlo do curenja žuči, a nekroza i opadanje tkiva u termički oštećenom području nakon operacije može uzrokovati i curenje žuči. Osim toga, često postoje veliki vagalni žučni kanali u krevetu žučne kese. Intraoperativna elektrokoagulacija ne može u potpunosti koagulirati, a može doći i do curenja žuči. Glavne manifestacije ozljede žučnih kanala su jaki bolovi u gornjem dijelu abdomena, visoka temperatura i žutica. Pacijenti sa tipičnim manifestacijama obično se liječe na vrijeme nakon operacije; Međutim, nekoliko pacijenata je pokazalo samo nadutost abdomena, nedostatak apetita, nisku temperaturu i progresivno pogoršanje. Takve pacijente treba pažljivo pratiti. Prijavljeno je da je intraabdominalna akumulacija žuči pronađena nekoliko mjeseci nakon operacije. Procijeniti da li postoji 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.

Drugi je nejasna anatomija jetrenog portala ili pogrešno stezanje desne hepatične arterije ili pravilne jetrene arterije zbog krvarenja arterije žučne kese. Postoje i izvještaji o ozljedi portalne vene tokom anatomije. Postoje izvještaji o nekrozi desne jetre uzrokovanoj pogrešnim stezanjem hepatične 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 reduce 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.