腹部外科腹腔镜微创手术360例临床观察
摘要
目的:评价腹腔镜微创手术在腹部外科临床应用的现状和价值,总结成功与经验,分析缺点与不足,在成功技术的基础上探索新的手术方法。
方法:回顾性分析吉林大学第一临床医学院普外科2004年1月至2006年1月所完成360例腹腔镜微创手术病例。
结果:实施腹腔镜微创手术13种(联合手术4种):腹腔镜胆囊切除术(LC)327例,腹腔镜胆总管切开探查T管引流术7例,肠粘连松解术3例,腹腔镜探查术3例,腹腔镜疝修补术3例,腹腔镜阑尾切除术2例,腹腔镜肝囊肿开窗引流术2例,腹腔镜十二指肠穿孔修补术1例,直肠癌根治术1例,LC联合阑尾切除术6例,LC联合肝囊肿开窗引流术2例,LC联合卵巢囊肿切除术1例,LC联合疝修补术1例。微创手术成功率98.9%,LC占微创手术总例数之91.1%。既往腹部手术史者LC成功率100%。急性胆囊炎LC成功率98.2%。术后抗生素使用率100%。LC手术时间35.43±3.23min,术后排气时间16.43±1.38h,术后住院日5.59±1.84d,住院费用8979.23±690.35元。中转开腹2例,中转率0.6%,腹腔内出血2例,出血率0.6%,胆管损伤1例,胆管损伤率0.3%,无死亡病例。
结论:随着经验的积累,设备的成熟,可以LC为中心,逐渐增加腹腔镜微创技术在腹部外科应用的广度和深度。建立完善的培训、资格认证制度,制定完善的围手术期治疗规范将更有力于腹腔镜微创技术健康迅速地发展。
Philipe Mouret created a new time of laparoscopic surgery, whofinished the first Laparoscopic Cholecystectomy (LC) successfully in1987. After Xun Zuwu actualized the first LC of China, thelaparoscopic surgery develop quickly. Today, LC is the "GoldenMethord" of teratment of cholecyst stone and polypus. Nobody candoubt the authority of laparoscopic surgery in the treatment ofnon-malignancy disease of cholecyst.Because of the development ofskill, experience, and instrument, the laparoscopic surgery change alot.Even the Whipple was finished by laparoscopic technique, whichalways seens to be the most difficult in the abdominal surgery. It is aworthful problem for surgery doctor that how to summarize anddevelop the experience to satisfy the medical request of patient. Theresearch actulaized a see-back clinical analusis of 360 cases oflaparoscopic surgery of the general surgery department, the 1sthospital of Ji Lin University, from Jan. 2004 to Jan. 2006. To evaluatethe actuality andvalue of laparoscopic sugery in abdominal sugery,and explore some new ways.
Male 136, female 224, age21~92, average 50.4, 45 cases ofabdomial operation history, include mid-up-abdomial operationhistory 30, such as gastrectomy and splenectomy. Fatness 85, menses2. 137 cases with system diseases, 76 cases wtih two and even more,include dumps, periodicity paralysis, hypophysoprivus syndrome. In
327 cases of LC, there are 311 cholecyst stone, 15 full stone, 7 bileduct stone, 95 polypus, 271 chronic cholecystitis, 56 acutecholecystitis.13 kinds of sugery: LC, LCTD, laparoscopy,laparoscopic appendectomy, laparoscopic hepaticyst drainage,laparoscopic operation of inguinal hernia, laparo-scopic repair ofduodenum perforation, laparoscopic operation of rectal cancer,laparoscopic operation of conglutination, laparoscopic ovariotomy,and4 unite opetation: LC combine append-ectomy, hepaticyst drainage,operation of inguinal hernia, ovariotomy.Before the operation, all of the heart, lung, liver, kidney will beexamined. The history and body palpation are required to know thesystem condition of patients. the antibiotics and gastrotube are used .urinetube is not need generally. CT and medicine treatment wererequired for patient with pancreatitis. patients with acute cholecystitiswere forbidden to feed, gastrotube and antibiotics were used, alaparoscopic emerge-ncy maybe need, or until the situation wascontroled.357 laparoscopic operation were finished, succeed rate 99.2%. 2cases changed to Open Cholecystectomy, rate 0.6%, 2 caseshemorrhage, rate 0.6%, 1 case of bile duct trauma, rate 0.3%, 1 caseincision infection, no death. Operation time 30.43±3.23min, exhausttime 16.43±1.38h, hospital day after operation 5.59±1.84d, hospitalexpend 8979.23±690.35yuan. 1 of 7 LCTD change to open operationfor setting T-tube. Operation time 93.56±7.24min, exhaust time 23.76
±1.18h, hospital day after operation 12.23±2.38do, hospital expend20725.83±1123.46yuan.All of the 3 patients accepted laparoscopichepaticyst drainage actived the 1st day, normal feed, nocomfortlessness. Operation time 38.17±8.27min,exhaust time 14.32±0.69h, hospital day after operation 3.29±0.57d, hospital expend8728.60±385.13yuan. 3 patients after laparoscopic operation ofinguinal hernia actived the 1st day, no comfortlessness, operation time63.50 ± 8.21min, exhaust time 8.65 ± 1.51h, hospital day afteroperation 6.62±1.42d, hospital expend 12042.73±892.62yuan.1laparoscopy was used for ileus, another was used for hemorrhage afterLC. 1 laparoscopic operation of rectal cancer was attempted, afterdissociation of the tumor, it change to Mile's operation.LC is the maximum operation in laparoscpic surgery, about91.1%.The rate of change to open operation is lower than others internal(about 1.4%) (P<0.05). The rate of bile duct truma is match to othersinternal (0.12~0.85%) (P<0.05). The reason of success : (1) Operatorswere skillful, and seasoned;(2) Be familiar with the anatomy of thegallbladder and Biliary Ducts;(3) Chang to open operation when need;(4) Adapt cases choosed;(5) Operate carefully;(6)Accept the advise;(7) Pay attention to the management of daily treatment. The successfullaparoscopic treatment rate of acute cholecystitis is 96.1%. Theexperience of operation: (1) Because of the stone, the bladder mayhave a high intensity, and grasping difficultly, puncture anddecompress the bladder, or partially excise the bladder wall. (2)
Carefully and dully dissection, near the bladder, even under the plasmmembrane. (3) Dully dissect the Calot triangle, identify the cystic ductand common bile duct. sometimes meticulous exposure of commonbile duct. (4) Affirm whether there is a hemorrhage or bile duct trauma.plearily swash abdomen. sometimes drainage-tube is necessary. (5)Change to open operation when difficulty is exist indeed. All of thepatients with history of abdominal operation. The experience ofoperation: (1) Ultrasonic examine and detailed operation history wererequired. Decide the tuocar place according the place and degree ofalvine conglutination. A open method was required, and faraway theold incision. (2) Abruptio alvine conglutination carefully, dully dissectthe Calot triangle, change to open operation when difficulty is existindeed. The operation of LCTD cure the cholecyst stone and the bileduct stone at the same time. Keepping the integrality of Oddi'ssphincter, and did not have more bad aftereffect. The T-tube alsosupplied ways to cure the remains stones of bile duct, and multi-stone.When there was only stone, no stricture, and was confirmed in theoperation, the common bile duct should be sewed once. Thelaparoscopic hepaticyst drainage operation were also successful. Thepatients healing quickly. Besides, 10 laparoscopic unite operationwere actualized, the truma and spend were both correspondingly few.It offered a new and safe way for the patients who suffer from two ormore abdominal surgery disease.In the LC cases, the principle of antibiotics was the same to the
Open Cholecystectomy. But tody a lot of research confirm that the useof antibiotics does not decrease the infection rate. There were 10 kindsof laparescopic operation, but rarely involved the diagnosis andtreatment of gastrointestinal disease. Compare to the ancientlyresearch, the rate of change to open operation decrease, but presencehemorrhage and bile duct trauma. So there was not a principle ofantibiotics for LC, and the doctors were short of trainning and assess.In a word, the laparoscopic surgery is well developed, andcontribute a new way to treat with abdominal surgery disease. Withmore and more experience, better equipment, it is a good way thatenlarge the content of laparoscopic surgery, certainly LC is the center.Constituting integrated doctor trainning and assess mechanism, andthe principle of antibio-tics will be helpful to the development oflaparoscopic surgery.
方法:回顾性分析吉林大学第一临床医学院普外科2004年1月至2006年1月所完成360例腹腔镜微创手术病例。
结果:实施腹腔镜微创手术13种(联合手术4种):腹腔镜胆囊切除术(LC)327例,腹腔镜胆总管切开探查T管引流术7例,肠粘连松解术3例,腹腔镜探查术3例,腹腔镜疝修补术3例,腹腔镜阑尾切除术2例,腹腔镜肝囊肿开窗引流术2例,腹腔镜十二指肠穿孔修补术1例,直肠癌根治术1例,LC联合阑尾切除术6例,LC联合肝囊肿开窗引流术2例,LC联合卵巢囊肿切除术1例,LC联合疝修补术1例。微创手术成功率98.9%,LC占微创手术总例数之91.1%。既往腹部手术史者LC成功率100%。急性胆囊炎LC成功率98.2%。术后抗生素使用率100%。LC手术时间35.43±3.23min,术后排气时间16.43±1.38h,术后住院日5.59±1.84d,住院费用8979.23±690.35元。中转开腹2例,中转率0.6%,腹腔内出血2例,出血率0.6%,胆管损伤1例,胆管损伤率0.3%,无死亡病例。
结论:随着经验的积累,设备的成熟,可以LC为中心,逐渐增加腹腔镜微创技术在腹部外科应用的广度和深度。建立完善的培训、资格认证制度,制定完善的围手术期治疗规范将更有力于腹腔镜微创技术健康迅速地发展。
Philipe Mouret created a new time of laparoscopic surgery, whofinished the first Laparoscopic Cholecystectomy (LC) successfully in1987. After Xun Zuwu actualized the first LC of China, thelaparoscopic surgery develop quickly. Today, LC is the "GoldenMethord" of teratment of cholecyst stone and polypus. Nobody candoubt the authority of laparoscopic surgery in the treatment ofnon-malignancy disease of cholecyst.Because of the development ofskill, experience, and instrument, the laparoscopic surgery change alot.Even the Whipple was finished by laparoscopic technique, whichalways seens to be the most difficult in the abdominal surgery. It is aworthful problem for surgery doctor that how to summarize anddevelop the experience to satisfy the medical request of patient. Theresearch actulaized a see-back clinical analusis of 360 cases oflaparoscopic surgery of the general surgery department, the 1sthospital of Ji Lin University, from Jan. 2004 to Jan. 2006. To evaluatethe actuality andvalue of laparoscopic sugery in abdominal sugery,and explore some new ways.
Male 136, female 224, age21~92, average 50.4, 45 cases ofabdomial operation history, include mid-up-abdomial operationhistory 30, such as gastrectomy and splenectomy. Fatness 85, menses2. 137 cases with system diseases, 76 cases wtih two and even more,include dumps, periodicity paralysis, hypophysoprivus syndrome. In
327 cases of LC, there are 311 cholecyst stone, 15 full stone, 7 bileduct stone, 95 polypus, 271 chronic cholecystitis, 56 acutecholecystitis.13 kinds of sugery: LC, LCTD, laparoscopy,laparoscopic appendectomy, laparoscopic hepaticyst drainage,laparoscopic operation of inguinal hernia, laparo-scopic repair ofduodenum perforation, laparoscopic operation of rectal cancer,laparoscopic operation of conglutination, laparoscopic ovariotomy,and4 unite opetation: LC combine append-ectomy, hepaticyst drainage,operation of inguinal hernia, ovariotomy.Before the operation, all of the heart, lung, liver, kidney will beexamined. The history and body palpation are required to know thesystem condition of patients. the antibiotics and gastrotube are used .urinetube is not need generally. CT and medicine treatment wererequired for patient with pancreatitis. patients with acute cholecystitiswere forbidden to feed, gastrotube and antibiotics were used, alaparoscopic emerge-ncy maybe need, or until the situation wascontroled.357 laparoscopic operation were finished, succeed rate 99.2%. 2cases changed to Open Cholecystectomy, rate 0.6%, 2 caseshemorrhage, rate 0.6%, 1 case of bile duct trauma, rate 0.3%, 1 caseincision infection, no death. Operation time 30.43±3.23min, exhausttime 16.43±1.38h, hospital day after operation 5.59±1.84d, hospitalexpend 8979.23±690.35yuan. 1 of 7 LCTD change to open operationfor setting T-tube. Operation time 93.56±7.24min, exhaust time 23.76
±1.18h, hospital day after operation 12.23±2.38do, hospital expend20725.83±1123.46yuan.All of the 3 patients accepted laparoscopichepaticyst drainage actived the 1st day, normal feed, nocomfortlessness. Operation time 38.17±8.27min,exhaust time 14.32±0.69h, hospital day after operation 3.29±0.57d, hospital expend8728.60±385.13yuan. 3 patients after laparoscopic operation ofinguinal hernia actived the 1st day, no comfortlessness, operation time63.50 ± 8.21min, exhaust time 8.65 ± 1.51h, hospital day afteroperation 6.62±1.42d, hospital expend 12042.73±892.62yuan.1laparoscopy was used for ileus, another was used for hemorrhage afterLC. 1 laparoscopic operation of rectal cancer was attempted, afterdissociation of the tumor, it change to Mile's operation.LC is the maximum operation in laparoscpic surgery, about91.1%.The rate of change to open operation is lower than others internal(about 1.4%) (P<0.05). The rate of bile duct truma is match to othersinternal (0.12~0.85%) (P<0.05). The reason of success : (1) Operatorswere skillful, and seasoned;(2) Be familiar with the anatomy of thegallbladder and Biliary Ducts;(3) Chang to open operation when need;(4) Adapt cases choosed;(5) Operate carefully;(6)Accept the advise;(7) Pay attention to the management of daily treatment. The successfullaparoscopic treatment rate of acute cholecystitis is 96.1%. Theexperience of operation: (1) Because of the stone, the bladder mayhave a high intensity, and grasping difficultly, puncture anddecompress the bladder, or partially excise the bladder wall. (2)
Carefully and dully dissection, near the bladder, even under the plasmmembrane. (3) Dully dissect the Calot triangle, identify the cystic ductand common bile duct. sometimes meticulous exposure of commonbile duct. (4) Affirm whether there is a hemorrhage or bile duct trauma.plearily swash abdomen. sometimes drainage-tube is necessary. (5)Change to open operation when difficulty is exist indeed. All of thepatients with history of abdominal operation. The experience ofoperation: (1) Ultrasonic examine and detailed operation history wererequired. Decide the tuocar place according the place and degree ofalvine conglutination. A open method was required, and faraway theold incision. (2) Abruptio alvine conglutination carefully, dully dissectthe Calot triangle, change to open operation when difficulty is existindeed. The operation of LCTD cure the cholecyst stone and the bileduct stone at the same time. Keepping the integrality of Oddi'ssphincter, and did not have more bad aftereffect. The T-tube alsosupplied ways to cure the remains stones of bile duct, and multi-stone.When there was only stone, no stricture, and was confirmed in theoperation, the common bile duct should be sewed once. Thelaparoscopic hepaticyst drainage operation were also successful. Thepatients healing quickly. Besides, 10 laparoscopic unite operationwere actualized, the truma and spend were both correspondingly few.It offered a new and safe way for the patients who suffer from two ormore abdominal surgery disease.In the LC cases, the principle of antibiotics was the same to the
Open Cholecystectomy. But tody a lot of research confirm that the useof antibiotics does not decrease the infection rate. There were 10 kindsof laparescopic operation, but rarely involved the diagnosis andtreatment of gastrointestinal disease. Compare to the ancientlyresearch, the rate of change to open operation decrease, but presencehemorrhage and bile duct trauma. So there was not a principle ofantibiotics for LC, and the doctors were short of trainning and assess.In a word, the laparoscopic surgery is well developed, andcontribute a new way to treat with abdominal surgery disease. Withmore and more experience, better equipment, it is a good way thatenlarge the content of laparoscopic surgery, certainly LC is the center.Constituting integrated doctor trainning and assess mechanism, andthe principle of antibio-tics will be helpful to the development oflaparoscopic surgery.
引文
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