Laparoscopic Cholecystectomy em i olsem wanem

Laparoscopic cholecystectomy i kamap wanpela bikpela operesen teknik, we planti sikmanmeri i save orait long en wantaim ol mak bilong liklik bagarap, liklik pen na hariap long kamap orait.

(1) Ol mak

Ol ston long bel i gat ol mak bilong en.

② Ol mak bilong sik 'cholecystitis' we i save stap longpela taim.

3Galstone wantaim diamita > 3cm.

④ Ol ston bilong bel i pulap.

Ol sua i kamap long 'gallbladder' we i gat ol mak bilong en na ol i soim long operesen.

Ol mak bilong 'acute cholecystitis' i pinis bihain long tritmen, na i gat ol samting bilong katim man.

Ol i ting olsem sikman i ken karim gut.

(2) Ol samting we i no stret

1-pela bikpela sik bilong 'calculous cholecystitis'.

Kronik atrofik 'calculous cholecystitis'.

Sekenderi 'choledocholithiasis'.

Histri bilong operesen antap long bel.

Fatpela bodi.

Hernia bilong bel ausait.

(3) Nogut tru

1-pela bikpela sik bilong 'cholecystitis' wantaim ol bikpela hevi, olsem 'gallbladder empyema', 'gangrene', 'perforation', na ol narapela samting.

Gallstone acute pancreatitis.

wantaim 'acute cholangitis'.

4-pela namba wan ston long 'bile duct' na 'intrahepatic bile duct stones'.

Obstructive jaundice.

⑥ Kensa bilong 'gallbladder'.

Ol i ting ol sua we i kamap long 'gallbladder' em i kensa.

Sirosis na 'portal hypertension'.

Namel na leit bel.

Sik long bel, sik 'peritonitis'.

'Chronic atrophic cholecystitis', 'gallbladder' i no winim 4.5cm × 1.5cm, 'wall thickness' > 0.5cm (ultrasonic measurement).

Em i save kamap wantaim ol sik bilong 'hemorrhagic' na 'coagulation dysfunction'.

Ol lain we ol bikpela hap bilong bodi bilong ol i no wok gut, i hat long karim operesen na anestesia, na ol lain i gat 'cardiac pacemaker' (ol i tambuim 'electrocoagulation' na 'electrocautery').

Jeneral kondisen i no gutpela, em i no gutpela long operesen o sikman i lapun, i no gat strongpela mak bilong 'cholecystectomy', 'diaphragmatic hernia'.

Ol samting we i soim olsem ol i ken mekim 'laparoscopic surgery' i wok long go bikpela wantaim divelopmen bilong teknoloji. Sampela sik we pastaim ol i no inap kisim operesen, ol i traim tu long pinisim long rot bilong 'laparoskopi'. Sapos ol i bin stretim liklik sik 'choledocholithiasis' long rot bilong 'laparoscopic surgery'. Bihain long ol i kisim ekspiriens, ol i ken stretim planti sik moa long rot bilong 'laparoscopic surgery'.

(4) Wok bilong katim man

Wokim 'pneumoperitoneum'. Mekim wanpela 'arc incision' long arere daunbilo bilong 'umbilical fossa', inap 10mm longpela. Sapos ol i bin katim bel daunbilo, katim skin long arere antap bilong 'umbilical fossa' bilong abrusim mak bilong operesen.

Opereta na namba wan asisten i holim ol 'cloth towel pliers' bilong apim 'abdominal wall' long tupela sait bilong 'umbilical fossa'. Opereta i holim nil bilong 'pneumoperitoneum' (Veress nil) wantaim bikpela pinga na indeks pinga bilong rait han bilong em, na putim strong long han bilong em, na sutim i go insait long hul bilong bel stret o i go long hul bilong bel.

Long taim bilong sutim, taim nil i brukim 'fascia' na 'peritoneum', yu pilim olsem em i brukim 'fascia' tupela taim; Skelim sapos het bilong nil i go insait long hul bilong bel. Yu ken konektim wanpela 'syringe' wantaim nomol 'saline'. Taim het bilong nil i stap insait long hul bilong bel, em i soim 'negative pressure'. Konektim masin bilong 'pneumoperitoneum'. Sapos presa bilong win i no winim 1.73kpa, dispela i soim olsem nil bilong 'pneumoperitoneum' i stap insait long hul bilong bel. Noken pulim win hariap tumas long stat. Yusim liklik 'flow inflation', 1 ~ 2L long wan wan minit.

Long wankain taim, lukluk long presa insait long bel bilong masin bilong 'pneumoperitoneum'. Presa long taim bilong inflesen i no ken winim 1.73kpa. Sapos em i antap tumas, dispela i soim olsem posisen bilong nil bilong 'pneumoperitoneum' i no stret, 'anesthesia' i no dip tumas na masol i no slek inap. Ol i mas mekim stretpela senis. Taim bel i stat long kamap bikpela na mak bilong 'liver dullness' i pinis, ol i ken senisim i go long 'high flow automatic inflation' inap long mak ol i makim pinis (1.73 ~ 2.00kpa). Long dispela taim, 'inflation' i 3 ~ 4L, bel bilong sikman i 'bulged' olgeta, na ol i ken statim operesen.

Liftim wol bilong bel wantaim ol 'towel pliers' long 'umbilical pneumoperitoneum needle' na sutim wantaim 10mm 'trocar'. Namba wan sut i gat wanpela kain "aipas", we em i wanpela step we i denja moa long 'laparoskopi'. Lukaut gut tru. Tanim trokar isi isi na putim nil i go insait wankain. Taim yu go insait long hul bilong bel, yu pilim olsem 'resistance' i pinis wantu tasol. Opim valv bilong win we i pas na ges i ken ranawe. Dispela em i sakses bilong 'puncture'. Konektim masin bilong 'pneumoperitoneum' long holim presa i stap wankain insait long hul bilong bel. Bihain putim 'laparoscope' na sutim long olgeta hap aninit long 'monitoring' bilong 'laparoscope'.

Planti taim, sutim 2cm aninit long 'xiphoid process' na putim 10mm 'casing' bilong 'discharge hook', 'clamp applicator' na ol narapela samting; Sutim 2cm aninit long arere bilong rait namel 'clavicular line' o 2cm aninit long arere bilong 'rectus abdominis' na arere bilong 'axillary front' wantaim 5mm 'trocar' long putim 'irrigator' na 'gallbladder fixed grasping forceps'. Long dispela taim, ol i pinisim wok bilong wokim 'artificial pneumoperitoneum' na ol wok redi bilong en.

Bikos long wokim 'pneumoperitoneum' na namba wan 'trocar puncture', ol bikpela rop bilong blut na 'intestine' insait long bel inap kisim bagarap, na i no isi long painim long taim bilong operesen. I no long taim i go pinis, planti manmeri i bin wokim wanpela liklik hul long 'umbilicus' bilong painim 'peritoneum' na putim stret 'trocar' i go insait long 'abdominal cavity' bilong pulim win. Bihain long ol i wokim gut 'pneumoperitoneum', ol i statim operesen.

Katim 'Calot triangle'. Holim nek bilong 'gallbladder' o 'Hartmann's bursa' wantaim 'grapping forceps' na 'traction' i go antap long rait sait. Em i gutpela long droim 'cystic duct' i go stret long 'common bile duct' bilong luksave klia long tupela, tasol yu no ken pulim 'common bile duct' i go long wanpela angle. Ol i katim 'serous membrane' long 'cystic duct' wantaim wanpela 'electrocoagulation hook', na ol i separetim 'cystic duct' na 'cystic artery', na ol i luksave long 'common bile duct' na 'common hepatic duct'. Long wanem em i stap klostu long 'common bile duct', ol i mas yusim 'electrocoagulation' liklik tasol long abrusim bagarap long 'common bile duct'. Yusim 'electrocoagulation hook' long separetim 'cystic duct' antap na daunstrim, na lukim rilesensip namel long 'cystic duct' na 'common bile duct'. Putim 'titanium clip' klostu long nek bilong 'gallbladder'. I mas i gat inap spes namel long tupela titanium klip. Titanium klip i mas stap 0.5cm longwe long 'common bile duct'. Katim namel long tupela titanium klip wantaim sisis, na noken yusim lektrik katim o lektrikkoagulasen long stopim bagarap long 'common bile duct' bikos long 'heat conduction'. Orait painim 'cystic artery' i stap baksait long en na katim wantaim 'titanium clip'. Bihain long yu katim 'gallbladder artery', noken pulim strong long abrusim brukim 'gallbladder artery', na lukluk gut long baksait bilong 'gallbladder'. Lukaut gut long 'gallbladder', 'electrocoagulation' o 'hemostasis' wantaim 'titanium clip'.

Katim 'cholecystectomy'. Holim nek bilong 'gallbladder' na pulim i go antap, rausim gut long wol bilong 'gallbladder', na helpim i mas helpim long pulim bilong mekim 'gallbladder' na 'liver bed' i gat sampela tensen. Rausim olgeta 'gallbladder' na putim antap long rait sait bilong 'liver'. Ol i bin 'hemostatic bed' bilong 'liver bed' long rot bilong 'electrocoagulation', na ol i bin wasim gut wantaim 'normal saline', na ol i bin sekim sapos i gat blut i ron na 'bile leakage' (ol i bin tromoi wanpela hap 'gauze' long 'hepatic hilum', na sekim sapos i gat 'bile staining' bihain long ol i rausim). Bihain long yu kisim olgeta wara insait long bel, putim 'laparoscope' i go long 'lower sleeve' bilong 'xiphoid process' na givim rot long 'umbilical incision', bai ol i ken rausim 'gallbladder' we i gat ol ston insait long en we i bikpela moa long 1cm long 'umbilical incision' wantaim lus straksa na isi long opim. Sapos ol ston i liklik, ol i ken rausim tu long hul bilong sutim aninit long 'xiphoid process'.

Rausim 'gallbladder'. Putim ol 'toothed claw forceps' i go insait long hul bilong bel long 'cannula' long 'umbilicus', holim 'residual end' bilong 'cystic duct' aninit long monitoring, isi isi pulim 'gallbladder' i go insait long 'cannula sheath' na pulim i kam aut wantaim 'cannula sheath'. Taim yu holim 'gallbladder', putim gut 'gallbladder' antap long 'liver' bilong abrusim bagarap long 'intestinal canal' long rot bilong ol sap 'forceps'. Sapos ston i bikpela o 'tension' bilong 'gallbladder' i bikpela, noken pulim em i kam aut wantaim strong long abrusim rup bilong 'gallbladder' na 'leak' bilong ol ston na 'bile' i go insait long hul bilong bel. Long dispela taim, ol i ken mekim hap we ol i katim i go bikpela wantaim ol 'vascular forceps' na rausim, o ol i ken skruim hap we ol i katim i go long 2.0cm wantaim wanpela 'expander'. Sapos ston i bikpela tumas, ol i ken skruim hap we ol i katim. Sapos 'bile' i lik i go insait long bel, ol i mas yusim wetpela 'gauze' long go insait long 'umbilical incision' bilong pulim 'bile'.

Sapos ston i bikpela tumas na yu no inap rausim long hap we yu katim, yu ken opim 'gallbladder' pastaim, pulim 'bile' insait long 'gallbladder' wantaim wanpela 'aspirator', na rausim wanpela wanpela bihain long yu brukim ston wantaim 'forceps'. Sapos ol i painim wanpela ston i pundaun insait long hul bilong bel, rausim. Bihain long sekim olsem i no gat blut na wara insait long hul bilong bel, pulimapim laparoskop, opim valv bilong kanula long rausim kabon daioksait ges insait long hul bilong bel, na bihain pulimapim kanula. Ol i katim wantaim 10mm 'cannula' wantaim liklik tret olsem 'fascia layer' inap 1 ~ 2 'stitches', na ol i pasim olgeta wan wan hap wantaim 'sterile adhesive film'.

(5) Ol bikpela hevi

Bagarap long 'bile duct'. Bagarap long 'bile duct' em i wanpela bikpela hevi we i save kamap planti taim taim ol i katim 'cholecystectomy' long 'laparoscopic'.

Namba bilong bagarap long 'bile duct' na 'bile leakage' em inap olsem 10%. Ol i mas givim gutpela luksave long en. Em i kamap bikos long 'anatomy' bilong 'Calot triangle' we i no klia, moa yet bikos ol i no was gut long ol kain kain 'common bile duct' o 'cystic duct'. Taim ol i separetim 'cystic duct', 'bile duct' i kisim bagarap long hat, i no gat 'bile leakage' long taim bilong operesen, na 'necrosis' na pundaun bilong 'tissue' long hap we i kisim bagarap bihain long operesen inap long kamapim 'bile leakage'. Na tu, planti taim i gat ol bikpela 'vagal bile ducts' insait long 'gallbladder bed'. Intraoperative electrocoagulation i no inap long 'coagulate' olgeta, na tu 'bile leakage' inap kamap. Ol bikpela mak bilong bagarap long 'bile duct' em i bikpela pen antap long bel, bikpela fiva na 'jaundice'. Ol sikmanmeri we i gat ol kain kain mak bilong sik ol i save kisim tritmen bihain long operesen; Tasol, sampela sikmanmeri i soim olsem bel bilong ol i op, ol i no laik kaikai, ol i no gat bikpela fiva na sik i go bikpela moa. Ol i mas lukluk gut long ol dispela kain sikman. Ol i bin ripot olsem ol i bin painim 'intraabdominal bile accumulation' sampela mun bihain long operesen. Long skelim sapos i gat 'bile leakage' em i dipen long 'ultrasound' o CT, na bihain ol i save konfemim long rot bilong 'fine needle puncture' aninit long stia bilong 'ultrasound' o CT o 'radionuclide hepatocholangiography'.

Bagarap long ol rop bilong blut. Wanpela em bikpela blut i kapsait long nil i kisim bagarap long 'abdominal aorta', 'iliac artery' o 'mesenteric vessels' taim ol i putim 'pneumoperitoneum' na 'trocar'. I gat planti ripot bilong dai we i kamap long 'trocar puncture'. Olsem na, bihain long 'pneumoperitoneum' i kamap gut, 'laparoscopy' i mas lukluk long bel olgeta wanpela taim long stopim bagarap long 'vascular'.

Narapela em i no klia 'anatomy' bilong 'hepatic portal' o rongpela 'clamping' bilong rait 'hepatic artery' o stretpela 'hepatic artery' bikos blut i ron long 'gallbladder artery'. I gat ol ripot tu long bagarap long 'portal vein' taim ol i wokim 'anatomy'. I gat ol ripot bilong 'right hepatic necrosis' we i kamap long rongpela 'clamping' bilong 'hepatic artery'.

Bagarap long bel. Ol bagarap long 'intestinal' em planti taim ol bagarap we i kamap long rot bilong 'electrocoagulation', moa yet bikos ol i no putim huk bilong 'electrocoagulation' long piksa bilong TV na ol i no painim. Bel pen, bel i op na fiva i save kamap bihain long operesen, na dispela i save kamapim bikpela sik 'peritonitis', na planti manmeri i save dai.

Blut i kapsait insait long bel bihain long operesen. Blut i kapsait insait long bel bihain long operesen em i wanpela bikpela hevi bilong laparoskopik operesen. Ol hap we i kisim bagarap em ol rop bilong blut klostu long 'gallbladder', olsem 'hepatic artery', 'portal vein' na 'abdominal aorta' o 'vena cava' taim ol i sutim 'periumbilical puncture'. Ol samting i kamap em 'hemorrhagic shock', 'abdominal bulge' na 'peripheral circulatory failure'. Ol i mas mekim 'open surgery' hariap long stopim blut.

Emfisema aninit long skin. Ol as bilong 'subcutaneous emphysema' em olsem: namba wan, taim ol i wokim 'pneumoperitoneum', nil bilong 'pneumoperitoneum' i no go insait long wol bilong bel, na bikpela presa kabon daioksait i go insait long skin; Namba tu, bikos long liklik sua long skin, 'trocar' i pas strong tru, na hul bilong 'peritoneum' i no pas tumas. Long taim bilong operesen, kabon daioksait ges i save lik i go insait long skin daunbilo bilong wol bilong bel. Taim ol i sekim bihain long operesen, ol i ken painim olsem bel i tanim tanim, planti taim ol i no givim spesel tritmen.

Ol narapela. Olsem 'incisional hernia', 'incisional infection' na 'abdominal abscess'.