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有關(guān)腹腔鏡膽囊切除術(shù)中轉(zhuǎn)開(kāi)腹97 例分析
【摘要】 探討腹腔鏡膽囊切除術(shù)(LC) 中轉(zhuǎn)開(kāi)腹對(duì)減少并發(fā)癥,提高手術(shù)質(zhì)量的重要性。 方法: 回顧分析總結(jié)97 例LC中轉(zhuǎn)開(kāi)腹的原因。 結(jié)果:主動(dòng)中轉(zhuǎn)開(kāi)腹(因解剖不清,尚未發(fā)生并發(fā)癥時(shí)即中轉(zhuǎn)開(kāi)腹)病例62 例,主要原因?yàn)镃alot 三角嚴(yán)重粘連、膽囊萎縮及解剖變異。術(shù)后沒(méi)有嚴(yán)重并發(fā)癥發(fā)生,術(shù)后平均住院日為9.72d ;被動(dòng)中轉(zhuǎn)開(kāi)腹(發(fā)生膽道損傷、大出血等并發(fā)癥后中轉(zhuǎn)開(kāi)腹) 病例35例,術(shù)后出現(xiàn)嚴(yán)重并發(fā)癥,術(shù)后平均住院日為17.71d。 結(jié)論:當(dāng)LC 術(shù)中遇到Calot 三角嚴(yán)重粘連、膽囊管結(jié)石嵌頓、膽囊萎縮及解剖變異等手術(shù)難度超出術(shù)者處理能力時(shí)應(yīng)適時(shí)主動(dòng)中轉(zhuǎn)開(kāi)腹以避免或減少并發(fā)癥的發(fā)生。【關(guān)鍵詞】 腹腔鏡膽囊切除術(shù) 轉(zhuǎn)開(kāi)腹
Abstract:Objective: To discuss the importance of conversion into surgery for decreasing complications and achieving better operative results during laparoscopic cholecystectomy (LC) . Methods:The causes of conversion into surgery were reviewed in 97 patients undergoing LC. Results:The main causes were intensive dense adhesion of Calot’s triangle ,shrunken gallbladder and abnormal anatomy in 62 cases undergoing LC of active conversion into surgery. The main causes were common bile duct injury and rapid hemorrhage in 35 cases receiving LC of passive conversion into surgery. The average postoperative stay for the active conversion into surgery were 9.72 days and 17.71 days for the passive conversion . In addition ,there was no complication in active conversion into surgery versus 8 complications in passive conversion into surgery . Conclusion:The active conversion into surgery should be considered at the right moment for preventing or decreasing complications of LC once intensive dense adhesion of Calot’s triangle ,stone incarceration on the neck of the gallbladder ,shrunken gallbladder and abnormal anatomy occurred during laparoscopic cholecystectomy.
Key words: Laparoscopic Cholecystectomy ; Conversion Laparotomy ; Cause
隨著腹腔鏡技術(shù)的推廣普及,LC 以其創(chuàng)傷小、痛苦小、瘢痕小、恢復(fù)快等優(yōu)越性已得到廣泛認(rèn)可。且隨著LC技術(shù)日益成熟,LC 的指征逐漸放寬,從而使相當(dāng)一部分較復(fù)雜病例的LC 得以實(shí)施,術(shù)中遇到的因病變或技術(shù)因素導(dǎo)致的特殊情況及疑難問(wèn)題也隨之增加,若手術(shù)處理不當(dāng)易損傷膽道和鄰近臟器,引起嚴(yán)重并發(fā)癥。為了保證手術(shù)的安全,避免或防止并發(fā)癥的發(fā)生,術(shù)前對(duì)手術(shù)難度的充分估計(jì)及術(shù)中適時(shí)中轉(zhuǎn)開(kāi)腹是非常重要的,F(xiàn)就我院LC 中轉(zhuǎn)開(kāi)腹原因分析如下:
1 臨床資料
我院自1993年2月至2006年12月共開(kāi)展腹腔鏡膽囊切除術(shù)6051例, 均因膽囊結(jié)石伴急性或慢性膽囊炎、膽囊息肉行LC 術(shù)。因各種原因中轉(zhuǎn)開(kāi)腹97 例(占1.60 %) ,其中擇期手術(shù)5407 例,中轉(zhuǎn)58 例(占1. 07 %);急癥手術(shù)644 例,中轉(zhuǎn)39 例(占6. 05 %) 。有國(guó)外文獻(xiàn)報(bào)道LC 中轉(zhuǎn)開(kāi)腹率為1. 6 %~11. 4 %[1],急癥LC中轉(zhuǎn)率高達(dá)20. 5 %[2] 。本組97 例,其中男45 例,女52 例,年齡14~72 歲,中位年齡38. 7 歲 。膽囊結(jié)石伴慢性膽囊炎22例,膽囊結(jié)石伴慢性膽囊炎急性發(fā)作31例, 膽囊結(jié)石伴急性膽囊炎39 例,膽囊息肉5 例。其中2 例合并2型糖尿病, 既往有腹部手術(shù)史12 例。
2 結(jié) 果
中轉(zhuǎn)開(kāi)腹97 例中膽囊與周圍炎性粘連、三角區(qū)解剖不清51 例,占52.58 %; 3 例膽囊與胃腸粘連,占3.09 %;其中2 例為膽囊十二指腸瘺, 占2.06 % ;1 例為膽囊結(jié)腸瘺, 占1.03 %; 膽囊管變異5 例,占5.15 %; 26 例懷疑膽道損傷,占26.80 %;7 例膽囊動(dòng)脈出血,占7.21 %;膽囊床廣泛滲血不止2 例,占2.06 %。全組97 例均一次性完成手術(shù),無(wú)死亡病例。主動(dòng)中轉(zhuǎn)開(kāi)腹62 例,均恢復(fù)良好,沒(méi)有嚴(yán)重并發(fā)癥發(fā)生,術(shù)后平均住院天數(shù)為9.72d ;被動(dòng)中轉(zhuǎn)開(kāi)腹35 例,手術(shù)難度加大,出現(xiàn)嚴(yán)重并發(fā)癥,其中膽瘺3 例,膽總管狹窄5 例,住院時(shí)間延長(zhǎng),術(shù)后平均住院天數(shù)為17.71d。
3 討 論
LC 中轉(zhuǎn)開(kāi)腹從原因上可分為主動(dòng)中轉(zhuǎn)開(kāi)腹和被動(dòng)中轉(zhuǎn)開(kāi)腹。主動(dòng)中轉(zhuǎn)開(kāi)腹是指術(shù)中發(fā)現(xiàn)難以完成的病變或解剖因素,但尚未發(fā)生并發(fā)癥時(shí)即中轉(zhuǎn)開(kāi)腹。本組97 例中轉(zhuǎn)開(kāi)腹的LC 病人,主動(dòng)中轉(zhuǎn)開(kāi)腹62 例(占63.92 %) 。隨著LC 技術(shù)的日益成熟,適應(yīng)癥也逐漸擴(kuò)大,從而由于病變?cè)驅(qū)е碌闹修D(zhuǎn)率隨之增高。被動(dòng)中轉(zhuǎn)開(kāi)腹主要與技術(shù)有關(guān),多指發(fā)生膽管損傷、大出血等并發(fā)癥后中轉(zhuǎn)開(kāi)腹。本組被動(dòng)中轉(zhuǎn)開(kāi)腹的35 例,均為膽管損傷和膽囊出血。多為術(shù)者獨(dú)立開(kāi)展LC 的初期階段,由
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