低压辅助悬吊式经脐入路腹腔镜胆囊切除11例报告(1)
【摘要】 目的 研究低CO2气腹压辅助腹壁悬吊经脐入路行腹腔镜胆囊切除术可行性和临床安全性。方法 辅助6 mm Hg CO2气腹，腹壁悬吊经脐入路建立操作空间及通道，常规腹腔镜胆囊切除，标本从脐部取出，检查无出血及胆漏，未放置引流管，缝合切口恢复脐部正常形态。结果 11例患者中除1例术中钛夹滑脱致胆囊动脉出血，气腹压增大至14 mm Hg成功止血完成手术外，余10例均顺利完成手术，胆囊切除时间36～48 min，平均42 min，术中出血10～30 ml，平均18 ml。术后无出血、胆漏、邻近脏器损伤等并发症发生，未用止痛药物，腹壁无明显手术瘢痕，术后3～5 d痊愈出院。结论 该项技术安全可行，更具微创美容优势，值得临床进一步探索。
【关键词】 低CO2气腹压； 悬吊式腹腔镜； 经脐入路腹腔镜； 腹腔镜胆囊切除术
Application of low pressure pneumoperitoneum combined with suspended and transumbilical endoscopic surgery in laparoscopic cholecystectomy:report of 11 cases YAO Jian. Sichuan Luzhou People's Hospital，Luzhou 646000，China
【Abstract】 Objective To evaluate feasibility and clinical safety of suspended and transumbilical endoscopic surgery in laparoscopic cholecystectomy. Methods To assisted the 6 mm Hg CO2 pneumoperitoneum，and establish operational space and access for the suspended and transumbilical endoscopic surgery in laparoscopic cholecystectomy. Gallbladder removed from the umbilicus by routine laparoscopic cholecystectomy with no bleeding or bile leakage，not draft tube placed. Then umbilical incision was sutured to restore the normal shape. Results Ten cases were performed successfully. Only another one case was successfully performed after stanching，in which the titanium clip slippage caused the bleeding of cystic artery and increase of abdominal pressure to about 14 mm Hg. The cholecystectomy operating time was 36-48 min (average 42 min) with 10-30 ml (average18 ml) of blood loss. No bleeding，bile leakage，damage to adjacent organs or other complications occurred postoperatively. No pain medications was used with no abdominal scar. The patient discharged from the hospital on the 3-5 days post-operation. Conclusion Suspended and transumbilical endoscopic surgery in laparoscopic cholecystectomy is feasibility and safety，with more minimally invasive cosmetic advantage. It is worthy of further exploration.
【Key words】 Lower CO2 pneumoperitoneum pressure； Suspension laparoscopic； Transumbilical laparoscopic surgery； Laparoscopic cholecystectomy
腹壁悬吊技术(Abdominal Wall lifting，AWL)系日本Nagai等[1]于1991年率先用于免气腹腹腔镜下胆囊切除而逐渐发展起来的。经脐入路内镜技术(transumbilical endoscopic surgery，TUES)是另一种腹壁无瘢痕手术，是现代微创外科研究的热点。将AML和TUES联合应用于临床国内已有报道[2]，本院也进行了探索[3.4]，取得较好的效果，但手术视野受限是较为突出的问题，为此本院尝试低压辅助下进行胆囊切除，检索国内外文献未见报道，现总结如下。
1 资料与方法
1.1 一般资料 本组11例患者，男4例，女7例，年龄20～65岁，平均41岁。经B超、CT检查及术后病检证实诊断。其中胆囊结石8例，胆囊息肉3例。病例选择标准：良性病变，无严重炎症发作及其他严重合并症。无手术及麻醉禁忌证，经患者和家属知情同意后，行低CO2气腹压辅助AWL+TUES腹腔镜胆囊切除术。
1.2 手术方法 术前准备及麻醉同常规腹腔镜胆囊切除术。气腹低压设定为6 mm Hg。按AWL+TUES的要求建立操作空间及通道，具体详见文献[4,5],胆囊切除同常规腹腔镜手术，标本从脐部取出，检查无出血及胆漏，未放置引流管，缝合切口，恢复脐部正常形态。
2 结果
1例术中钛夹滑脱致胆囊动脉出血，增大气腹压至14 mm Hg成功止血后完成手术。余10例均顺利完成手术，胆囊切除时间36～48 min，平均42 min，术中出血10～30 ml，平均18 ml。术后无出血、胆漏、邻近脏器损伤等并发症发生，未用止痛药物，腹壁无明显手术瘢痕，术后3～5 d痊愈出院。
3 讨论
常规腹腔镜术中需充入CO2以建立气腹，CO2气腹对机体的影响已引起众多学者的重视。气腹法腹腔镜可导致较多并发症，如气胸、气体栓塞、高碳酸血症、心律失常、血栓形成等[6]。笔者的对比研究证实，免气腹LC在手术创伤，术后疼痛、住院费、平均动脉压、心律、呼气末CO2、气道峰压等方面更具优越性[7，8]。, http://www.100md.com(姚健)
【关键词】 低CO2气腹压； 悬吊式腹腔镜； 经脐入路腹腔镜； 腹腔镜胆囊切除术
Application of low pressure pneumoperitoneum combined with suspended and transumbilical endoscopic surgery in laparoscopic cholecystectomy:report of 11 cases YAO Jian. Sichuan Luzhou People's Hospital，Luzhou 646000，China
【Abstract】 Objective To evaluate feasibility and clinical safety of suspended and transumbilical endoscopic surgery in laparoscopic cholecystectomy. Methods To assisted the 6 mm Hg CO2 pneumoperitoneum，and establish operational space and access for the suspended and transumbilical endoscopic surgery in laparoscopic cholecystectomy. Gallbladder removed from the umbilicus by routine laparoscopic cholecystectomy with no bleeding or bile leakage，not draft tube placed. Then umbilical incision was sutured to restore the normal shape. Results Ten cases were performed successfully. Only another one case was successfully performed after stanching，in which the titanium clip slippage caused the bleeding of cystic artery and increase of abdominal pressure to about 14 mm Hg. The cholecystectomy operating time was 36-48 min (average 42 min) with 10-30 ml (average18 ml) of blood loss. No bleeding，bile leakage，damage to adjacent organs or other complications occurred postoperatively. No pain medications was used with no abdominal scar. The patient discharged from the hospital on the 3-5 days post-operation. Conclusion Suspended and transumbilical endoscopic surgery in laparoscopic cholecystectomy is feasibility and safety，with more minimally invasive cosmetic advantage. It is worthy of further exploration.
【Key words】 Lower CO2 pneumoperitoneum pressure； Suspension laparoscopic； Transumbilical laparoscopic surgery； Laparoscopic cholecystectomy
腹壁悬吊技术(Abdominal Wall lifting，AWL)系日本Nagai等[1]于1991年率先用于免气腹腹腔镜下胆囊切除而逐渐发展起来的。经脐入路内镜技术(transumbilical endoscopic surgery，TUES)是另一种腹壁无瘢痕手术，是现代微创外科研究的热点。将AML和TUES联合应用于临床国内已有报道[2]，本院也进行了探索[3.4]，取得较好的效果，但手术视野受限是较为突出的问题，为此本院尝试低压辅助下进行胆囊切除，检索国内外文献未见报道，现总结如下。
1 资料与方法
1.1 一般资料 本组11例患者，男4例，女7例，年龄20～65岁，平均41岁。经B超、CT检查及术后病检证实诊断。其中胆囊结石8例，胆囊息肉3例。病例选择标准：良性病变，无严重炎症发作及其他严重合并症。无手术及麻醉禁忌证，经患者和家属知情同意后，行低CO2气腹压辅助AWL+TUES腹腔镜胆囊切除术。
1.2 手术方法 术前准备及麻醉同常规腹腔镜胆囊切除术。气腹低压设定为6 mm Hg。按AWL+TUES的要求建立操作空间及通道，具体详见文献[4,5],胆囊切除同常规腹腔镜手术，标本从脐部取出，检查无出血及胆漏，未放置引流管，缝合切口，恢复脐部正常形态。
2 结果
1例术中钛夹滑脱致胆囊动脉出血，增大气腹压至14 mm Hg成功止血后完成手术。余10例均顺利完成手术，胆囊切除时间36～48 min，平均42 min，术中出血10～30 ml，平均18 ml。术后无出血、胆漏、邻近脏器损伤等并发症发生，未用止痛药物，腹壁无明显手术瘢痕，术后3～5 d痊愈出院。
3 讨论
常规腹腔镜术中需充入CO2以建立气腹，CO2气腹对机体的影响已引起众多学者的重视。气腹法腹腔镜可导致较多并发症，如气胸、气体栓塞、高碳酸血症、心律失常、血栓形成等[6]。笔者的对比研究证实，免气腹LC在手术创伤，术后疼痛、住院费、平均动脉压、心律、呼气末CO2、气道峰压等方面更具优越性[7，8]。, http://www.100md.com(姚健)