Laparoskopik xoletsistektomiya qanday amalga oshiriladi

Laparoskopik xoletsistektomiya etuk jarrohlik usuliga aylandi, bu kam travma, kamroq og'riq va tez tiklanish xususiyatlariga ega bo'lgan bemorlarning ko'pchiligi tomonidan qabul qilinadi.

(1) Ko'rsatkichlar

① Symptomatic gallstones.

② Symptomatic chronic cholecystitis.

③ Gallstone with diameter >3 sm.

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) Nisbiy kontrendikatsiyalar

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) Mutlaq kontrendikatsiya

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 sm (ultratovush o'lchovi).

Gemorragik kasalliklar va koagulyatsion disfunktsiya bilan birga keladi.

Muhim aʼzolar funksiyasi toʻliq boʻlmagan, operatsiya va behushlikka toqat qilish qiyin boʻlganlar, yurak stimulyatori boʻlganlar (elektrokoagulyatsiya va elektrokoteriya taqiqlanadi).

Umumiy ahvoli yomon, operatsiyaga yaroqsiz yoki bemor qarigan, xoletsistektomiya, diafragma churrasining kuchli belgisi yo'q.

Texnologiyaning rivojlanishi bilan laparoskopik jarrohlik uchun ko'rsatmalar doirasi kengayib bormoqda. Dastlab jarrohlik uchun kontrendikatsiya bo'lgan ba'zi kasalliklarni ham laparoskopiya bilan tugatishga harakat qilingan. Ikkilamchi xoledoxolitiaz laparoskopik jarrohlik yo'li bilan qisman hal qilingan bo'lsa. Kerakli tajribaga ega bo'lgandan so'ng, ko'proq kasalliklarni laparoskopik jarrohlik yo'li bilan davolash mumkin.

(4) Jarrohlik muolajasi

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.

Operator va birinchi yordamchi qorin devorini kindik bo'shlig'ining har ikki tomonidan ko'tarish uchun mato sochiq pensesini ushlab turishadi. Operator o'ng qo'lining bosh barmog'i va ko'rsatkich barmog'i bilan pnevmoperitoneum ignasini (Veress ignasi) ushlab, bilagiga kuch qo'ydi va qorin bo'shlig'iga vertikal yoki bir oz qiyshiq ravishda tos bo'shlig'iga sanchiladi.

Teshilish jarayonida igna fastsiya va qorin pardani kesib o'tganda, ikki marta yorilish hissi paydo bo'ladi; Ignaning uchi qorin bo'shlig'iga kirganmi yoki yo'qligini aniqlang. Oddiy sho'r suvli shpritsni ulash mumkin. Igna uchi qorin bo'shlig'ida bo'lsa, u salbiy bosimni ko'rsatadi. Pnevmoperitoneum apparatini ulang. Inflyatsiya bosimi 1,73kpa dan oshmasa, bu pnevmoperitoneum ignasi qorin bo'shlig'ida ekanligini ko'rsatadi. Boshida juda tez shishirmang. Past oqim inflyatsiyasidan foydalaning, daqiqada 1 2L.

Shu bilan birga, pnevmoperitoneum mashinasida intraperitoneal bosimni kuzating. Inflyatsiya paytida bosim 1,73 kpa dan oshmasligi kerak. Agar u juda baland bo'lsa, bu pnevmoperitoneum ignasining pozitsiyasi noto'g'ri ekanligini ko'rsatadi, behushlik juda sayoz va mushak etarli darajada bo'shashmaydi. Tegishli sozlashni amalga oshirish kerak. Qorin bo'rtib chiqa boshlaganda va jigar xiralik chegarasi yo'qolganda, uni oldindan belgilangan qiymatga (1,73 2.00kpa) erishilgunga qadar yuqori oqimli avtomatik inflyatsiyaga o'zgartirish mumkin. Bu vaqtda inflyatsiya 3 4L, bemorning qorni butunlay bo'rtib ketgan va operatsiyani boshlash mumkin.

Qorin devorini sochiq pensesi bilan kindik pnevmoperitoneum ignasi bilan ko'taring va 10 mm troakar bilan teshing. Birinchi ponksiyonda ma'lum bir "ko'rlik" mavjud, bu laparoskopiyada yanada xavfli qadamdir. Qo'shimcha ehtiyot bo'ling. Troakarni sekin aylantiring va igna ichiga teng ravishda kiriting. Qorin bo'shlig'iga kirganda, qarshilik to'satdan yo'qolishi hissi paydo bo'ladi. Yopiq havo klapanini oching va gaz chiqadi. Bu ponksiyonning muvaffaqiyati. Qorin bo'shlig'ida doimiy bosimni saqlab turish uchun pnevmoperitoneum mashinasini ulang. Keyin laparoskopni qo'ying va laparoskopning monitoringi ostida har bir nuqtada ponksiyon qiling.

Odatda, xiphoid jarayonidan 2 sm pastda teshib qo'ying va tushirish kancasi, qisqich aplikatori va boshqa asboblar uchun 10 mm korpusni qo'ying; Irrigator va o't pufagiga mahkam ushlab turuvchi qisqichlarni qo'yish uchun o'ng o'rta klavikulyar chiziqning qovurg'a chetidan 2 sm pastda yoki qorin to'g'ri ichakning tashqi chetidan 2 sm pastda va qo'ltiq osti old qismining 5 mm troakar bilan ponksiyon qiling. Ayni paytda sun'iy pnevmoperitoneum va tayyorgarlik ishlari yakunlandi.

Pnevmoperitoneum ishlab chiqarilishi va birinchi troakar ponksiyoni tufayli qorin bo'shlig'idagi katta qon tomirlari va ichaklar tasodifan shikastlanishi mumkin va operatsiya vaqtida uni topish oson emas. So'nggi paytlarda ko'p odamlar qorin pardani topish va inflyatsiya uchun qorin bo'shlig'iga to'g'ridan-to'g'ri troakarni qo'yish uchun kindikda kichik teshik ochdilar. Pnevmoperitoneum muvaffaqiyatli ishlab chiqarilgandan so'ng, operatsiya boshlandi.

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.

Agar tosh juda katta bo'lsa, kesilgan joydan olib tashlash uchun siz ham birinchi navbatda o't pufagini ochib, o't pufagidagi o'tni aspirator bilan so'rishingiz va toshni forseps bilan maydalagandan keyin birma-bir chiqarib olishingiz mumkin. Qorin bo'shlig'iga tosh tushishi aniqlansa, uni olib tashlang. Qorin bo'shlig'ida qon va suyuqlik yo'qligini tekshirgandan so'ng, laparoskopni tortib oling, qorin bo'shlig'idagi karbonat angidrid gazini chiqarish uchun kanül valfini oching va keyin kanülni chiqarib oling. 10 mm kanülli kesma 1 2 chok uchun fastsiya qatlami sifatida yupqa ip bilan tikiladi va har bir kesma steril yopishqoq plyonka bilan yopiladi.

(5) Asosiy asoratlar

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

Safro yo'llarining shikastlanishi va safro sızıntısı insidansı taxminan 10% ni tashkil qiladi. Bunga etarlicha e'tibor berish kerak. Bu asosan Calot uchburchagining noaniq anatomiyasi, ayniqsa umumiy o't yo'li yoki kist yo'lining keng tarqalgan o'zgarishiga nisbatan hushyorlikning yo'qligi bilan bog'liq. Mukovistsidozni ajratishda o't yo'li beixtiyor termik shikastlangan, operatsiya vaqtida safro oqishi kuzatilmagan, operatsiyadan keyin termal shikastlangan hududdagi to'qimalarning nekrozi va tushishi ham safro oqishiga olib kelishi mumkin. Bundan tashqari, o't pufagi to'shagida ko'pincha katta vagal o't yo'llari mavjud. Intraoperativ elektrokoagulyatsiya to'liq koagulyatsiya qila olmaydi va safro oqishi ham shakllanishi mumkin. O't yo'llari shikastlanishining asosiy ko'rinishlari qorinning yuqori qismida kuchli og'riqlar, yuqori isitma va sariqlikdir. Odatdagidek namoyon bo'lgan bemorlar operatsiyadan keyin o'z vaqtida davolanadilar; Biroq, ba'zi bemorlarda faqat qorin bo'shlig'i, ishtahaning etishmasligi, past harorat va progressiv kuchayganligi ko'rsatilgan. Bunday bemorlarni diqqat bilan kuzatib borish kerak. Operatsiyadan bir necha oy o'tgach, qorin bo'shlig'ida safro to'planishi aniqlanganligi xabar qilingan. Safro oqishi bor-yo'qligini aniqlash uchun asosan ultratovush yoki KTga bog'liq bo'lib, keyin ultratovush yoki KT yoki radionuklid gepatokolangiografiyasi rahbarligida nozik igna teshilishi bilan tasdiqlanadi.

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.

Ikkinchisi - jigar darvozasining noaniq anatomiyasi yoki o't pufagi arteriyasidan qon ketishi tufayli o'ng jigar arteriyasi yoki to'g'ri jigar arteriyasining noto'g'ri siqilishi. Shuningdek, anatomiya paytida portal venaning shikastlanishi haqida xabarlar mavjud. Jigar arteriyasini noto'g'ri siqish natijasida kelib chiqqan o'ng jigar nekrozi haqida xabarlar mavjud.

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.