Njani i-Laparoscopic Cholecystectomy

I-cholecystectomy ye-Laparoscopic iye yaba yindlela yotyando oluvuthiweyo, olwamkelwa luninzi lwezigulane ezineempawu zokuxhatshazwa okuncinci, intlungu engaphantsi kunye nokubuyisela ngokukhawuleza.

(1) Imiqondiso

① Iimpawu zenyongo.

② Iimpawu ze-cholecystitis ezingapheliyo.

③ Ilitye lenyongo elinedayamitha> 3cm.

④ Amatye enyongo azaliswe.

⑤ Izilonda ze-protuberant ezibonakalisiweyo kunye nokuhlinzwa kwi-gallbladder.

⑥ Iimpawu ze-cholecystitis ezibukhali zaye zakhululeka emva konyango, kwaye kwakukho iimpawu zotyando.

⑦ Kuqikelelwa ukuba isigulane sinyamezeleke kakuhle.

(2) Izichaso ezihambelanayo

① Uhlaselo oluqatha lwe-calculous cholecystitis.

② Chronic atrophic calculous cholecystitis.

③ Choledocholithiasis yesibini.

④ Imbali yotyando lwesisu esiphezulu.

⑤ Umzimba otyebileyo.

⑥ I-hernia yesisu yangaphandle.

(3) Ukuchasana ngokupheleleyo

① I-cholecystitis ebukhali eneengxaki ezinzulu, ezifana ne-gallbladder empyema, i-gangrene, ukubhoboza, njl.

② I-Gallstone i-pancreatitis ebukhali.

③ Ngecholangitis ebukhali.

④ Amatye asisiseko aqhelekileyo etyholo lenyongo kunye namatye e-intrahepatic bile.

⑤ Ijaundice ethintelayo.

⑥ Umhlaza wesinyi.

⑦ Izilonda ze-protuberant kwi-gallbladder zikrokrelwa ukuba zinomhlaza.

⑧ I-Cirrhosis kunye ne-portal hypertension.

⑨ Ukukhulelwa okuphakathi nasemva kwexesha.

⑩ Usulelo lwesisu, i-peritonitis.

I-atrophic cholecystitis engapheliyo, i-gallbladder engaphantsi kwe-4.5cm × 1.5cm, ubukhulu bodonga> 0.5cm (umlinganiselo we-ultrasonic).

Ikhatshwa zizifo ze-hemorrhagic kunye ne-coagulation dysfunction.

Abo banomsebenzi ongaphelelanga wezitho ezibalulekileyo, kunzima ukunyamezela ukusebenza kunye ne-anesthesia, kunye ne-cardiac pacemaker (i-electrocoagulation kunye ne-electrocautery ayivunyelwe).

Imeko eqhelekileyo ihlwempuzekile, ayifanelekanga ukusebenza okanye isigulane sidala, akukho mqondiso oqinileyo we-cholecystectomy, i-diaphragmatic hernia.

Umda wezibonakaliso zotyando lwe-laparoscopic uyanda ngophuhliso lobuchwepheshe. Ezinye izifo ezazichasene noqhaqho ekuqaleni ziye zazanywa ukuba zigqitywe nge-laparoscopy. Ukuba i-choledocholithiasis yesibini iye yasonjululwa ngokuyinxenye ngotyando lwe-laparoscopic. Emva kokufumana amava ayimfuneko, izifo ezininzi zinokunyangwa ngotyando lwe-laparoscopic.

(4) Inkqubo yotyando

① Yenza ipneumoperitoneum. Yenza i-arc yokusikwa ecaleni kwencam engezantsi yefossa ye-umbilical, malunga ne-10mm ubude. Ukuba amazantsi esisu sele enziwe utyando, sike ulusu kumphetho ongentla wenkaba ukuphepha isiva sokuqala sotyando.

Umsebenzisi kunye nomncedisi wokuqala ngamnye ubambe iipliyisi zetawuli zokuphakamisa udonga lwesisu kumacala omabini e-umbilical fossa. Umqhubi ubambe inaliti ye-pneumoperitoneum (inaliti ye-Veress) ngobhontsi kunye nomnwe wesalathisi sesandla sakhe sasekunene, wasebenzisa amandla esihlahleni sakhe, kwaye wahlatywa kumngxuma wesisu ngokuthe nkqo okanye ngokuthobileyo kumgodi we-pelvic.

Kwinkqubo yokubhoboza, xa inaliti iqhekeza i-fascia kunye ne-peritoneum, kukho ingqiqo yokuphumelela kabini; Gweba ukuba incam yenaliti ingenile kumngxuma wesisu. Isirinji ene-saline eqhelekileyo inokudityaniswa. Xa incam yenaliti ikwindawo yesisu, ibonisa uxinzelelo olubi. Qhagamshela umatshini wepneumoperitoneum. Ukuba uxinzelelo lokunyuka kwamaxabiso aludluli i-1.73kpa, kubonisa ukuba inaliti yepneumoperitoneum ikwindawo yesisu. Musa ukufutha ngokukhawuleza kakhulu ekuqaleni. Sebenzisa ukunyuka kwamaxabiso okuphantsi, 1 ~ 2L ngomzuzu.

Kwangaxeshanye, jonga uxinzelelo lwe-intraperitoneal kumatshini wepneumoperitoneum. Uxinzelelo ngexesha lokunyuka kwamaxabiso akufanele ludlule i-1.73kpa. Ukuba iphezulu kakhulu, ibonisa ukuba indawo yenaliti ye-pneumoperitoneum ayilunganga, i-anesthesia ayinzulu kakhulu kwaye i-muscle ayikhululekanga ngokwaneleyo. Kufuneka kwenziwe uhlengahlengiso olufanelekileyo. Xa isisu siqala ukugqabhuka kwaye umda wobuthuntu besibindi uyanyamalala, unokutshintshwa kwixabiso eliphezulu lokunyuka kwamaxabiso okuzenzekelayo de ixabiso elimiselweyo (1.73 ~ 2.00kpa) lifikelelwe. Ngeli xesha, ukunyuka kwamaxabiso ngu-3 ~ 4L, isisu sesigulane siphelile ngokupheleleyo, kwaye umsebenzi unokuqaliswa.

Phakamisa udonga lwesisu kunye neepliers zetawuli kwi-umbilical pneumoperitoneum inaliti kunye nokuhlatywa nge-10mm trocar. I-puncture yokuqala ine "ubumfama" obuthile, obuyinyathelo eliyingozi ngakumbi kwi-laparoscopy. Lumka ngakumbi. Jikelezisa i-trocar kancinci kwaye ungene inaliti ngokulinganayo. Xa ungena kwisigxina sesisu, kukho ukuvakalelwa kukuba ukuchasana kuyanyamalala ngokukhawuleza. Vula ivalve yomoya evaliweyo kunye nokuphuma kwegesi. Le yimpumelelo ye-puncture. Xhuma umatshini we-pneumoperitoneum ukugcina uxinzelelo oluqhubekayo kwisigxina sesisu. Emva koko faka i-laparoscope kwaye ubhobhoze kwindawo nganye phantsi kolawulo lwe-laparoscope.

Ngokuqhelekileyo, gqobhoza i-2cm ngaphantsi kwenkqubo ye-xiphoid kwaye ubeke i-10mm casing ye-hook yokukhupha, i-clamp applicator kunye nezinye izixhobo; I-Puncture ye-2cm ngaphantsi kwe-costal edge yomgca we-clavicular ophakathi okanye i-2cm ngaphantsi komda wangaphandle we-rectus abdominis kunye ne-costal edge ye-axillary front kunye ne-5mm trocar ngokulandelanayo ukubeka kwi-irrigator kunye ne-gallbladder egxininise i-forceps yokubamba. Ngeli xesha, i-pneumoperitoneum yokwenziwa kunye namalungiselelo agqityiwe.

Ngenxa yokwenziwa kwe-pneumoperitoneum kunye ne-trocar puncture yokuqala, imithwalo yegazi emikhulu kunye namathumbu kwindawo yesisu inokulimala ngengozi, kwaye akulula ukuyifumana ngexesha lokusebenza. Kungekudala, abantu abaninzi baye bavula indawo encinci kwi-umbilicus ukuze bafumane i-peritoneum kwaye bafake ngokuthe ngqo i-trocar kwisigxina sesisu sokunyuka kwamaxabiso. Emva kokwenziwa ngempumelelo kwepneumoperitoneum, utyando lwaqaliswa.

② Hlukanisa unxantathu weCalot. Bamba intamo ye-gallbladder okanye i-Hartmann's bursa kunye ne-forceps yokubamba kunye nokutsala ukuya phezulu ngasekunene. Kungcono ukuzoba i-cystic duct perpendicular to the common bile duct ukwenzela ukuhlula ngokucacileyo ezi zimbini, kodwa qaphela ukuba ungazobi i-bile duct kwi-angle. I-membrane ye-serous kwi-cystic duct yasikwa nge-hook ye-electrocoagulation, i-cystic duct kunye ne-cystic artery yayihlukaniswe ngokuzimeleyo, kwaye i-bile duct eqhelekileyo kunye ne-hepatic duct eqhelekileyo yahlulwa. Ekubeni isondele kwi-bile duct eqhelekileyo, i-electrocoagulation kufuneka isetyenziswe kancinci kangangoko ukuphepha ukulimala ngengozi kwi-bile duct eqhelekileyo. Sebenzisa i-electrocoagulation hook ukwahlula i-cystic duct phezulu nasezantsi, kwaye ubone ubudlelwane phakathi kwe-cystic duct kunye ne-bile duct eqhelekileyo. Beka ikliphu ye-titanium kufutshane nentamo ye-gallbladder ngokusemandleni. Kufuneka kubekho umgama owaneleyo phakathi kweekliphu ezimbini zetitanium. Ikliphu ye-titanium kufuneka ubuncinane ibe yi-0.5cm kude nombhobho oqhelekileyo wenyongo. Sika phakathi kweekliphu ezimbini ze-titanium kunye nesikere, kwaye ungasebenzisi ukusika kombane okanye i-electrocoagulation ukukhusela umonakalo kwi-bile duct eqhelekileyo ngenxa yokushisa ukushisa. Emva koko fumana i-cystic artery emva kwayo kwaye uyinqumle ngekliphu ye-titanium. Emva kokunqumla umthambo we-gallbladder, musa ukutsala nzima ukuze ugweme ukuphula umthambo we-gallbladder, kwaye ubeke ingqalelo kwisebe elingasemva le-gallbladder. Khulula ngononophelo i-gallbladder, i-electrocoagulation okanye i-hemostasis ngekliphu ye-titanium.

③ Cholecystectomy. Gcoba intamo ye-gallbladder kwaye uyitsale phezulu, yikrazule ngononophelo kunye nodonga lwe-gallbladder, kwaye umncedisi kufuneka ancedise ekutsaleni ukwenza i-gallbladder kunye nebhedi yesibindi ibe noxinzelelo oluthile. Gcoba ngokupheleleyo i-gallbladder kwaye uyibeke kwicala eliphezulu lasekunene kwesibindi. Ibhedi yesibindi yayine-hemostatic nge-electrocoagulation, ihlanjululwe ngononophelo nge-saline eqhelekileyo, kwaye ihlolwe ukopha kunye nokuvuza kwe-bile (iqhekeza le-gauze lachithwa kwi-hilum ye-hepatic, kwaye ihlolwe ukuba i-bile staining emva kokususwa). Emva kokufunxa onke amanzi kwindawo yesisu, tshintshela i-laparoscope kwi-sleeve engezantsi yenkqubo ye-xiphoid kwaye unike indlela yokuqhawula i-umbilical, ukwenzela ukuba i-gallbladder equkethe amatye angaphezu kwe-1cm inokukhutshwa kwi-umbilical incision kunye nesakhiwo esikhululekile kunye nokwandiswa okulula. Ukuba amatye amancinci, anokukhutshwa kwakhona kumngxuma wokubhoboza phantsi kwenkqubo ye-xiphoid.

④ Susa i-gallbladder. Beka inzipho ezinamazinyo kumngxuma wesisu ukusuka kwicannula kwinkaba, bamba isiphelo sentsalela yombhobho we-cystic phantsi kweliso elibukhali, tsala inyongo ngokucothayo kwi-cannula sheath kwaye uyikhuphe kunye ne-cannula sheath. Xa ubamba i-gallbladder, qaphela ukubeka i-gallbladder kwisibindi ukuze ugweme ukulimala ngengozi kwi-intestinal canal nge-forceps ebukhali. Ukuba ilitye likhulu okanye uxinzelelo lwe-gallbladder luphezulu, musa ukuyikhupha ngamandla ukuze ugweme ukugqabhuka kwe-gallbladder kunye nokuvuza kwamatye kunye ne-bile kwi-cavity yesisu. Ngeli xesha, i-incision inokunyuswa kunye ne-vascular forceps kwaye ikhutshwe, okanye i-incision inokwandiswa ukuya kwi-2.0cm kunye ne-expander. Ukuba ilitye likhulu kakhulu, ukusika kunokwandiswa. Ukuba inyongo ivuza kumngxuma wesisu, igauze emanzi iyakusetyenziselwa ukungena ukusuka kumngxuma wenkaba ukufunxa inyongo.

Ukuba ilitye likhulu kakhulu ukuba lingasuswa kwindawo yokusikwa, unokuvula i-gallbladder kuqala, ufunxe inyongo nge-aspirator, kwaye uyikhuphe nganye nganye emva kokutyumza ilitye nge-forceps. Ukuba ilitye lifunyenwe ukuba liwele kumngxuma wesisu, likhuphe. Emva kokujonga ukuba akukho gazi kunye nolwelo kwindawo yesisu, khupha i-laparoscope, vula i-valve ye-cannula ukukhupha i-carbon dioxide gas kwindawo yesisu, uze uyikhuphe i-cannula. I-incision ene-10mm cannula i-sutured ngentambo encinci njenge-fascia layer ye-1 ~ 2 stitches, kwaye i-incision nganye ivalwe ngefilimu encamathelayo eyinyumba.

(5) Iingxaki ezinkulu

① Ukwenzakala kwithunjana. Ukwenzakala kwibhobhobhobhosi yenye yezona ngxaki zixhaphakileyo nezimandundu ze-laparoscopic cholecystectomy.

Izehlo zokulimala kwe-bile duct kunye nokuvuza kwe-bile malunga ne-10%. Kufuneka kunikwe ingqalelo ngokwaneleyo. Ikakhulu ngenxa ye-anatomy engacacanga yeCalot triangle, ngakumbi ukungabikho kokuphaphela ngokuchasene nokwahluka okuqhelekileyo kwe-bile duct okanye i-cystic duct. Xa kwahlula i-cystic duct, i-bile duct yonakaliswa ngokungalindelekanga, kwakungekho ukuvuza kwe-bile ngexesha lokusebenza, kunye ne-necrosis kunye nokuwa kwezicubu kwindawo eyonakaliswe thermally emva kokuhlinzwa kunokubangela ukuvuza kwe-bile. Ukongeza, kuhlala kukho i-vagal bile ducts enkulu kwibhedi ye-gallbladder. I-electrocoagulation ye-Intraoperative ayikwazi ukudibanisa ngokupheleleyo, kwaye ukuvuza kwe-bile kunokusekwa. Iimpawu eziphambili zokulimala kwe-bile duct ziintlungu ezibuhlungu eziphezulu zesisu, umkhuhlane ophezulu kunye ne-jaundice. Izigulane ezinezibonakaliso eziqhelekileyo zidla ngokuphathwa ngexesha emva kokuhlinzwa; Nangona kunjalo, izigulana ezimbalwa zibonise kuphela ukuphazamiseka kwesisu, ukunqongophala kokutya, umkhuhlane ophantsi kunye nokunyuka okuqhubekayo. Izigulana ezinjalo kufuneka ziqwalaselwe ngokusondeleyo. Kwaxelwa ukuba ukuqokelela kwe-bile ye-intraabdominal kwafunyanwa kwiinyanga ezimbalwa emva kokusebenza. Ukugweba ukuba kukho ukuvuza kwenyongo ikakhulu kuxhomekeke kwi-ultrasound okanye kwi-CT, kwaye emva koko ingqinwe ngokuhlatywa kwenaliti ecolekileyo phantsi kolwalathiso lwe-ultrasound okanye i-CT okanye i-radionuclide hepatocholangiography.

② Ukwenzakala kwemithambo. Olunye kukopha okukhulu okubangelwa kukwenzakala kwincapha yenaliti kwi-aorta yesisu, umthambo we-iliac okanye iinqanawa ze-mesenteric ngexesha lokubekwa kwe-pneumoperitoneum kunye ne-trocar. Kukho iingxelo ezininzi zokufa okubangelwa yi-trocar puncture. Ke ngoko, emva kwe-pneumoperitoneum ephumeleleyo, i-laparoscopy kufuneka ijonge yonke isisu kube kanye ukukhusela ukulahleka kwemithambo yegazi.

Enye i-anatomy engacacanga ye-hepatic portal okanye ukubambelela okungalunganga komthambo we-hepatic wasekunene okanye umthambo we-hepatic ofanelekileyo ngenxa yokopha komthambo we-gallbladder. Kukho neengxelo zokulimala kwe-portal vein ngexesha le-anatomy. Kukho iingxelo ze-hepatic necrosis echanekileyo ebangelwa kukubamba okungalunganga komthambo we-hepatic.

③ Ukwenzakala emathunjini. Ukonzakala kwamathumbu ubukhulu becala kukwenzakala ngengozi okubangelwa yi-electrocoagulation, ikakhulu ngenxa yokuba ihuku ye-electrocoagulation ayifakwanga kumfanekiso wokujongwa kwe-TV kwaye ayifunyanwa. Iintlungu zesisu, ukugqithiswa kwesisu kunye nomkhuhlane kwenzeka emva kokuhlinzwa, okukhokelela kwi-peritonitis enzima, kwaye ukufa kwayo kuphezulu.

④ I-postoperative intraperitoneal hemorrhage. I-postoperative intraperitoneal hemorrhage nayo enye yeengxaki ezinzulu zotyando lwe-laparoscopic. Amalungu awonzakeleyo ikakhulu yimithambo yegazi ekufutshane nenyongo, njenge-hepatic artery, portal vein kunye ne-aorta yesisu okanye i-vena cava ngexesha lokuhlatywa kwe-periumbilical. Imiboniso yaba kukothuka kwe-hemorrhagic, i-bulge yesisu kunye nokusilela kwe-peripheral circulatory. Utyando oluvulekileyo kufuneka lwenziwe ngokukhawuleza ukunqanda ukopha.

⑤ I-emphysema engaphantsi kwesikhumba. Izizathu ze-emphysema engaphantsi kwesikhumba zimi ngolu hlobo lulandelayo: okokuqala, xa kusenziwa ipneumoperitoneum, inaliti yepneumoperitoneum ayizange ingene kudonga lwesisu, kwaye uxinzelelo oluphezulu lwekharbon dioksidi lwangena kwi-subcutaneous; Okwesibini, ngenxa yesikhumba esincinci, i-trocar ifakwe ngokuqinileyo, kwaye umngxuma wokubhoboza we-peritoneum ukhululekile. Ngexesha lokusebenza, i-carbon dioxide gas ivuza kuluhlu olusezantsi lwesikhumba sodonga lwesisu. Uvavanyo lwasemva kokuhlinzwa lunokufumana ukubizwa kwe-abdominal subcutaneous twisting pronunciation, ngokubanzi ngaphandle konyango olukhethekileyo.

⑥ Abanye. Okufana ne-hernia yokusika, usulelo lokusikeka kunye nethumba lesisu.