摘要:目的:探討腹腔鏡膽囊大部分切除在復雜膽囊結石手術中應用的可行性及安全性。方法:回顧性分析2003年1月至2008年10月間41例行腹腔鏡膽囊部分切除術的復雜膽囊結石病人。行腹腔鏡膽囊切除術指征為:膽囊管不能明確辨認時,諸如:膽囊積膿、Mirris綜合征、Calot三角致密粘連呈“冰凍樣”、萎縮性膽囊等。手術方法為:切除膽囊前壁,取凈結石,腹腔置管引流。結果:41例復雜膽囊結石病人中1例中轉開腹手術外,其余全部在腹腔鏡下完成,手術時間為45～145分鐘,平均(57.42±19.41)分鐘,1例術后出現膽漏,其余術后住院時間為2～7天。 結論:在膽囊三角不能安全辨認前提下,對于復雜膽囊結石行腹腔鏡膽囊部分切除術是一種安全的手術方式,不但能簡化手術、降低手術風險,而且能避免行開腹手術治療。Abstract: Objective: To study the possibility and safty of laparoscopic subtotal cholecystectomy in complicated cholecystectomy. Methods: Laparoscopic subtotal cholecystectomy was performed when the cystic duct cannot be identified safely, such as empyema cholecystitis, Mirris syndrome, frozen Calot’triangle, shrunken gallbladder. The operation consists of resecting the anterior wall of the gallbladder, removing all stones, and placing a large drain. 41 patients who underwent a laparoscopic subtotal cholecystectomy between 1 January 2003 and 31 October 2008 were retrospectively analyzed. Results: Fortyone cases of complex laparoscopic cholecystectomy were performed. 1 cases in which were changed to open cholecystectomy. Operating time was 45145 min, average (57.42±19.41) min. 1 cases were reoperated because of the bile leak. Hospital stays were 27 days. Conclusion: Laparoscopic subtotal cholecystectomy is a viable procedure during cholecystectomy in which Calot’s triangle cannot be safely dissected. It may simplify the operation and decrease the risk in complicated cholecystectomy and averts the need for a laparotomy.
Objective To investigate clinical efficacy of laparoscopic cholecystectomy via left side approach for patients with acute cholecystitis. Methods One hundred and twenty patients with acute cholecystitis from January 2015 to May 2017 were collected. All of the patients were divided into observation group and control group according to the operative mode, with 60 cases in each group. In the observation group, the patients were treated by laparoscopic cholecystectomy via left side approach using the ligation-free technique to the main trunk of the cystic artery; in the control group, the patients were treated by the conventional laparoscopic cholecystectomy. After treatment, the operative situation, postoperative recovery, and incidence of postoperative complications were compared between these two groups. Results Compared with the control group, the operative time, first anal exhaust time, hospitalization stay, leukocytes recovery time, and coagulation function recovery time were shortened and the intraoperative bloods loss was reduced in the observation group, the differences were statistically significant (P<0.05). Furthermore, the overall postoperative complication incidence rate of the observation group was significantly lower than that of the control group (P<0.05). Conclusion For patients with acute cholecystitis, laparoscopic cholecystectomy via left side approach using ligation-free technique to main trunk of cystic artery is reliable and safe, which can effectively improve operative situation, shorten operative time, promote recovery of patient, and reduce incidence of postoperative complications.
ObjectiveTo investigate the efficacy and safety of percutaneous transhepatic gallbladder drainage (PTGBD) combined with early laparoscopic cholecystectomy (LC) in the treatment of elderly patients with high-risk acute cholecystitis.MethodsThe clinical data of 128 elderly patients with high-risk acute cholecystitis admitted to Department of Hepatobiliary Surgery in Dazhou Central Hospital from January 2015 to January 2019 were retrospectively analyzed. Among them, 62 patients underwent PTGBD combined with early LC treatment (PTGBD+early LC group), 66 patients underwent PTGBD combined with delayed LC treatment (PTGBD+delayed LC group). Comparison was performed on the operative time, intraoperative blood loss, conversion to laparotomy rate, postoperative indwelling time, postoperative hospitalization time, total hospitalization time, and complication.ResultsPTGBD was successfully performed in all patients, and the symptoms were relieved within 72 hours. There was no significant difference in operative time, intraoperative blood loss, conversion to laparotomy rate, postoperative indwelling time, postoperative hospitalization time, and total complication rate between the two groups (P>0.05), but the total hospitalization time of the PTGBD+early LC group was shorter than that of the PTGBD+delayed LC group (P<0.001). There was no second operation and death in both two groups. The 128 patients were followed-up for 2–50 months with a average of 19 months. Results of follow-up after operation showed that the patients did not complain of obvious abdominal pain, abdominal distension, chills, fever, jaundice, and other discomforts.ConclusionsFor elderly patients with high-risk acute cholecystitis, early LC is a safe and effective treatment for patients with good overall condition after PTGBD. It can not only shorten the total hospitalization time, but also significantly shorten the time of tube-taking and improve the quality of life of patients. It has important clinical application value.
Objective To compare the clinical efficacy and safety of suturesuspension single hole laparoscopic cholecystectomy and traditional laparoscopic cholecystectomy (LC) in the treatment of gallbladder disease. Methods A total of 86 cases who got treatment in our hospital from February 2014 to July 2015 were collected prospectively, and then 86 cases were divided into 2 groups: 43 cases of control group underwent LC and 43 cases of experimental group underwent suturesuspension single hole laparoscopic cholecystectomy. Clinical efficacy and safety of the two groups were compared. Results ① Complication. No one suffered from bile duct injury, bile leakage, bile duct stricture, and umbilical hernia; but there were 2 cases suffered from complications in control group, including 1 case of abdominal pain and 1 case of bloating, and the morbidity was 4.65% (2/43). The morbidity of experimental group was 0, there was no significant difference between the 2 groups in the morbidity (P>0.05). During the follow-up period, 1 case suffered from long-term compilation in experimental group, and 2 cases in normal group, there was no significant difference in the long-term complication between the 2 groups (P>0.05). ② Operation and hospitalization. The blood loss and operation time in the experimental group were lower than those of the control group (P<0.05), but there was no significant difference in the hospital stay and hospitalization cost between the 2 groups (P>0.05). ③ Postoperative electrolytes, liver and kidney function. The levels of Na+ and K+ in the experimental group were higher than those of the control group (P<0.05), and the levels of alanine aminotransferase and aspartate aminotransferase were lower than those of control group (P<0.01), but there was no significant difference in the blood urea nitrogen and serum creatinine between the 2 groups (P>0.05). ④ The recovery of gastrointestinal function after surgery. The anal exhaust time and bowel sounds recovery time in experimental group were shorter than those of the control group (P<0.01). Conclusion Suturesus-pension single hole laparoscopic cholecystectomy in the treatment of gallbladder disease is safe, effective, and minimally invasive, and it has little disturbance on gastrointestinal function and liver function, which is worthy of clinical application.
ObjectiveTo explore the optimal surgical timing of sequential laparoscopic cholecystectomy (LC) following percutaneous cholecystostomy (PC) in the patients with acute cholecystitis, so as to provide a clinical reference. MethodsThe patients who underwent PC and then sequential LC in the Fifth Affiliated Hospital of Xinjiang Medical University from March 2021 to July 2023 were selected based on the inclusion and exclusion criteria, who were categorized into 3 groups: the short interval group (3–4 weeks), the intermediate interval group (5–8 weeks), and the long interval group (>8 weeks) based on the time interval between the PC and LC. The gallbladder wall thickness before LC, operative time, intraoperative blood loss, postoperative hospitalization time, total hospitalization time, time and cases of drainage tube placement, admission to intensive care unit, conversion to open surgery, occurrence of complications, and total hospitalization costs were compared among the 3 groups. ResultsA total of 99 patients were enrolled, including 25 in the short interval group, 41 in the intermediate interval group, and 33 in the long interval group. The data of patients among the 3 groups including demographic characteristics, blood routine, C-reactive protein, interleukin-6, fibrinogen, international standardized ratio, liver function indicators, and comorbidities had no statistical differences (P>0.05). The gallbladder wall thickness before LC and the operative time, intraoperative blood loss, postoperative hospitalization time, total hospitalization time, time and cases of drainage tube placement, admission to intensive care unit, conversion to open surgery, occurrence of complications, and total hospitalization costs during and after LC had statistical differences among the 3 groups (P<0.05). These indicators of the intermediate interval group were better than those of the other two groups by the multiple comparisons (P<0.05), but which had no statistical differences except total hospitalization costs (P=0.019) between the short interval group and the long interval group (P>0.05). ConclusionAccording to the results of this study, the optimal surgical timing of sequential LC following PC is 5–8 weeks, however, which needs to be further validated by large sample size and multicenter data.
ObjectiveTo preliminarily explore application and effectiveness of stimulation learning based on a live demonstration system in hepatobiliary surgical training, using laparoscopic cholecystectomy (LC) as an example. MethodsFrom March 2023 to February 2024, 60 surgical residents undergoing a 4-month standardized residency training at the Liver Transplant Center of West China Hospital, Sichuan University, were randomly assigned into an observation group (n=30) and a control group (n=30) using a random number table. The observation group received stimulation learning based on the live demonstration system, while the control group received traditional teaching methods. At the end of the training, both groups underwent an operative assessment on LC and completed a resident satisfaction questionnaire. Operative assessment used critical view of safety (CVS) scoring to evaluate surgical safety. Resident satisfaction was assessed using a self-designed questionnaire covering five domains: stimulating the learning atmosphere, increasing learning engagement, improving surgical proficiency, enhancing the understanding of surgical complications, and recognition of the teaching model. The final results were categorized as positive or negative evaluations. ResultsThe observation group had significantly higher CVS score than the control group (4.2±1.3 vs. 2.8±1.7, t=3.57, P=0.001). All 60 questionnaires were collected, and the observation group reported significantly higher positive evaluations in improving surgical proficiency, enhancing the understanding of surgical complications, and recognition of the teaching model compared to the control group (P<0.05). There were no statistically significant differences between the two groups regarding positive evaluations for stimulating the learning atmosphere and increasing learning engagement (P>0.05). ConclusionThe results of this study suggest that the stimulation learning model based on a live demonstration system demonstrates good effectiveness in hepatobiliary surgical training and can improve the quality of surgical teaching during standardized residency training for surgical residents.
Objective To explore the nursing effect of using Neiguan acupoint massage combined with chewing gum in patients undergoing day-case laparoscopic cholecystectomy. Methods A prospective study was conducted on patients who underwent day-case laparoscopic cholecystectomy in West China Hospital of Sichuan University between March 2023 and March 2024. The patients were randomly divided into the control group and the intervention group according to a random number table. The control group received routine care, while the intervention group received chewing gum and Neiguan acupoint massage intervention at the P6 acupoint in addition to routine care. The incidence of postoperative nausea and vomiting (PONV), pain scores, gastrointestinal function recovery time, medication use, and hospitalization related indicators were compared between the two groups of patients after surgery. Results A total of 298 patients were included. Among them, there were 163 cases in the control group and 135 cases in the intervention group. The incidence of PONV at 0.5 and 2 hours after surgery and the pain scores at 6, 12, and 24 hours after surgery in the intervention group were lower than those in the control group (P<0.05). The first bowel sounds recovery time, anal exhaust time, and eating time in the intervention group were shorter than those in the control group (P<0.05). Twenty-four hours after surgery, the usage rate of analgesic drugs (6.67% vs. 14.11%) and the usage rate of rescue antiemetic drugs (2.96% vs. 8.59%) in the intervention group were lower than those in the control group (P<0.05). There was no statistically significant difference in the delayed discharge rate or total cost between the two groups (P>0.05). The nursing satisfaction of the intervention group was higher than that of the control group (99.26% vs. 93.25%, P<0.05). Conclusions After the combination of Neiguan acupoint massage and chewing gum intervention in patients undergoingin day-case laparoscopic cholecystectomy, the PONV incidence and pain are significantly reduced, gastrointestinal functions recover faster, drug use rate is low, patient nursing satisfaction is high. This method can be promoted and applied.
ObjectiveTo compare the effectiveness and safety of laparoscopic cholecystectomy (LC) plus laparoscopic common bile duct exploration (LCBDE) with LC plus endoscopic retrograde cholangiopancreatography (ERCP) for patients with concomitant cholelithiasis and choledocholithiasis by using meta-analysis.MethodsWe searched PubMed, Cochrane Library、EMBASE, Chinese Biomedical Literature Database, Chinese Science and Technology Academic Journal, Chinese Journal Full-text Database and Wanfang database to identify relevant articles from their inception to 31 October 2018. A meta-analysis was carried out using the RevMan 5.3 software.ResultsA total of 13 RCTs were included in this meta-analysis, 747 cases received LC+LCBDE and 761 cases underwent LC+ERCP. The meta-analysis results showed that no significant difference between the LC+LCBDE group and the LC+ERCP group in terms of common bile duct (CBD) stone clearance rate [RR=0.99, 95%CI (0.95, 1.02), P=0.87] and overall complications [RR=0.94, 95%CI (0.72, 1.22), P=0.64]. The LC+LCBDE group had higher rate of postoperative bile leakage rate [RR=3.87, 95%CI (2.01, 7.42), P<0.000 1] than that LC+ERCP group. However, the LC+LCBDE group had lower rate of postoperative pancreatitis [RR=0.28, 95%CI (0.14, 0.55), P=0.002] than that LC+ERCP group.ConclusionsBoth LC+LCBDE and LC+ERCP are equivalent in CBD stone clearance rate and overall complications, LC+LCBDE is associated with a higher postoperative bile leakage rate and lower rate of postoperative pancreatitis, appropriate treatment should be selected according to the individual patient’s condition.
Objective To explore the feasibility of single incision laparoscopic cholecystectomy in the treatment of acute cholecystitis, and to provide evidence based medicine for clinical treatment. Methods A total of 160 cases of acute cholecystitis who received treatment in our hospital from Jan. 2012 to Dec. 2015 were randomly divided into single incision group (n=80, received single incision laparoscopic cholecystectomy) and three incisions group (n=80, received three incisions laparoscopic cholecystectomy). The clinical and laboratory indexes were compared between the 2 groups. Results Compared with the three incisions group, there were statistically significant differences in the operation time, incision pain score, and subjective satisfaction, which were better in single incision group (P<0.05). But there was no significant difference in the blood loss, bed time, anal exhaust time, recovery time of intestinal peristalsis, hospitalization time, incidence of complication (including abdominal infection, bile duct injury, biliary fistula, and incision infection), ratios of T cell subsets (including CD3, CD4, and CD8 T cell), levels of immunoglobulin (including IgA, IgG, and IgM), and level of C reactive protein (P>0.05). Conclusions The effectiveness of single incision laparoscopic cholecystectomy is as good as three incisions laparoscopic cholecystectomy, but this single incision laparoscopic surgery is difficult, and its indications should be cautious. Single incision laparoscopic cholecystectomy is more suitable for patients undergoing elective cholecystectomy.
ObjectiveTo investigate the clinical value of laparoscopic cholecystectomy following “A-B-D” approach applied in the operation of acute suppurative or gangrenous cholecystitis.MethodsWe sought out 45 patients diagnosed as acute suppurative or gangrenous cholecystitis and treated by laparoscopic cholecystectomy following the “A-B-D” approach in People’s Hospital of Leshan from Sep. 2019 to Dec. 2020 as the observation group (ABD observation group), and sought out 50 patients with the same diseases but treated by conventional laparoscopic cholecystectomy from Jun. 2018 to Aug. 2019 as the matched group (conventional matched group). We analyzed and compared the parameters related to safety and efficacy of the two groups retrospectively.ResultsA total of 95 patients were included, including 45 patients in the ABD observation group (26 cases of acute suppurative cholecystitis, 19 cases of acute gangrenous cholecystitis) and 50 patients in the conventional matched group (24 cases of acute suppurative cholecystitis, 26 cases of acute gangrenous cholecystitis). There were no significant differences in age, gender, body mass index, disease composition, gallbladder condition, and preoperative complications between the two groups (P>0.05). There was no bile duct injury case in the ABD observation group (0), while there were 4 cases (8.0%) in the conventional matched group, but the statistical results showed no statistical significance between the two groups (P=0.054). One case (2.2%) in the ABD observation group converted to laparotomy, which was significantly lower than the 10 cases (20.0%) in the conventional matched group, and the difference was statistically significant (P=0.017). In addition, there were no significant differences for other parameters including operative time, postoperative hospital stay, incidences of intraoperative bleeding and postoperative bleeding between the two groups (P>0.05).ConclusionsThe laparoscopic cholecystectomy following the “A-B-D” approach can help distinguish the anatomical structure of cystic duct and extrahepatic bile duct clearly, and it can help prevent biliary tract injury effectively and reduce the probability of conversion to laparotomy. It is worthy of clinical application and promotion, especially in the majority of county hospitals.