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find Author "谢芳" 3 results
  • 胆囊切除误伤胆管17例报道

    近15年来,我院对结石性胆囊炎行胆囊切除987例,其中胆管损伤9例。收治院外胆囊切除损伤胆管5例,协助他院处理腹腔镜胆囊切除(LC)损伤胆管3例,共17例,男8例,女9例; 年龄37~68岁,均有结石性胆囊炎病史,病程为1~25年,平均7年。单纯性胆囊切除术12例,胆囊切除合并胆道探查2例,LC中转开腹3例; 再次手术最早13 d,最晚为术后35 d。损伤类型: 胆管误扎6例,胆管横断加缝扎5例,胆管撕裂伤5例,胆管缝闭后因梗阻破裂1例。再手术胆道修补T管引流7例,胆肠吻合10例; 治愈15例,因严重肝功能衰竭及感染败血症、休克死亡2例。  讨论 胆囊切除术中胆管误伤或误扎造成胆道梗阻而需再次剖腹,教训极为深刻。本报道中17例胆囊切除时误伤或误扎胆管,其主要原因有: ①术者技术欠熟练,对肝、胆囊、胆囊管、肝总管、胆总管、胆囊动脉及胆囊三角的解剖关系不熟悉或过于自信,术中追求速度,一时疏忽大意; ②切口选择不当,片面追求小切口,手术视野暴露差,胆囊动脉变异,出血时盲目钳夹、缝扎止血,将胆管误扎或误伤; ③对胆囊管、胆总管及肝总管三者关系辨认不清时或结扎胆囊管时过度牵拉胆囊,胆总管成角,将胆总管误认为胆囊管,误扎胆管; ④术中麻醉欠佳,患者躁动或血压不稳,为了尽快结束手术,还未分清胆囊管和胆总管就盲目切管结扎,将胆管误扎。本报道中13例胆囊切除术后2 d出现进行性黄疸,未想到是胆管误扎或误伤。最早术后第13天行胆道探查,最晚术后35 d才行胆道探查。有1例术后13 d切口裂开、流出混浊绿色液体时才急行剖腹探查。因此,应重视防治这种损伤。根据本报道的病例之经验及教训,结合文献,提出以下要点: ①严格掌握胆囊切除术的适应证及手术时机。对非结石性胆囊炎及急性胆囊炎病程超过72 h、正值炎症水肿严重时,最好先用非手术疗法控制感染后再行胆囊切除,对粘连、炎症严重者可先行胆囊引流或大部切除手术。②要求术中良好麻醉,忌在麻醉差、光源照明不好及手术视野暴露欠佳的情况下手术。③要认清Calot三角的解剖关系,认准三管,忌盲目钳夹、缝扎止血。要辨清胆囊管、肝总管及胆总管,分清三者关系后才能结扎离断,不要过分牵拉胆囊,过度牵拉胆囊易造成胆总管成角,造成误扎[1]。④要坚持手术规范化,不要勉强操作,胆管解剖变异复杂,在充血水肿、炎症粘连及经验局限的情况下手术要谨慎,手术医生要保持良好的精神境界,充沛的体力,避免疲劳操作,主刀与助手要通力合作,默契配合。⑤胆囊切除术毕,在清洁术野时要用干白纱布轻擦,观察有无黄染,术中发现有胆管损伤或可疑损伤时应保持良好心态,不应急躁,可请上级医师或有经验医师,包括请外院医生会诊处理,避免处理不当; 关腹后转院比术中会诊造成的后果可能会更严重; LC发现有胆管损伤,要中转开腹手术处理,本报道中外院会诊病例处理满意。⑥术中偶遇凶猛出血时不能慌乱,应沉着面对,用术者左手食指伸入Winslow孔,拇指在肝十二指肠韧带上下压与食指合拢,紧压进肝方向的血流,吸尽积血,找准出血处,钳夹结扎或缝合; 对嵌顿在胆囊管或壶腹部结石及肿大之胆囊,妨碍Calot三角解剖时,应先推开或取出结石,或穿刺排除部分胆汁。认清胆囊管、胆总管及肝总管三管的关系后再结扎切除胆囊管。⑦对胆囊切除术后出现黄疸,要高度怀疑胆管损伤,适时进行B超、CT、MRI、ERCP及化验检查,及早明确诊断; 胆管损伤超过48~72 h者,正值炎症反应期,不宜根治性再手术,有胆瘘者应充分引流,若是梗阻性黄疸,对症治疗等炎症控制,胆管扩张增厚,择期手术为佳。⑧再手术应根据胆管损伤的部位、性质、程度及患者全身及局部状态,选择修补、吻合或内引流术式[2]。⑨首次或再手术之围手术期都应加强保肝、抗感染、营养支持等处理,力争杜绝再手术。参考文献1 王蔚蓝, 钱章选, 孙海明. 开腹胆囊切除术胆管损伤的高危险因素及对策 [J]. 肝胆胰外科杂志, 2008; 20(2):1382 张英宝.  医院性胆管损伤12例报道 [J].  中国普外基础与临床杂志, 2007; 14(5):622

    Release date:2016-09-08 10:57 Export PDF Favorites Scan
  • 十二指肠损伤10例分析

    我院于1991~2006年期间手术治疗十二指肠损伤患者10例,男9例,女1例; 年龄9~55岁。患者受伤后均立即出现腹部剧痛、腹胀、呕吐。损伤后就诊时间5~25 h,伤后5 h内确诊为十二指肠损伤者2例,伤后5~20 h确诊者3例,伤后20~25 h确诊者5例。术前均进行B超、X线片、CT等检查,其中3例诊断为肠穿孔,经剖腹才得以明确诊断。本组7例十二指肠降部破裂伤均行双层内翻缝合修补,清除裂口周围及腹腔积血、积液后,将胃肠减压管置入十二指肠修补处以远,术后进行持续胃肠减压,使十二指肠处于空虚状态。2例十二指肠全段血肿,经切开浆膜清除血肿后,缝合浆膜,与十二指肠降部破裂伤修补病例一样,持续胃肠减压,腹腔引流,有效抗感染、禁食、静脉营养,术后2例并发十二指肠瘘,经再次修补扩大引流,修补后再次并发肠瘘1例,第3次剖腹修补、引流治愈。院外转来1例,因十二指肠降部损伤术后发生肠瘘,经第2次修补加引流,虽经多种综合治疗,终因腹腔感染、全身衰竭,于伤后第35天死亡。本组十二指肠损伤裂口小、腹腔污染轻,经修补、引流、禁食、胃肠减压、抗菌、静脉营养等有效处理,术后恢复较顺利。痊愈9例,死亡1例,住院最短14 d,最长90 d。  讨论 十二指肠在腹腔内解剖部位较深,毗邻许多重要血管,周围的器官结构复杂,功能重要,手术显露困难,一旦损伤可造成严重后果。其肠管壁大部分位于腹膜后,受伤多见于车祸事故,腹部或背部受到暴力、冲击或挤压致十二指肠损伤,同时可并有多脏器损伤。闭合性十二指肠损伤有以下特点: ①腹部或背部受伤后,立即出现剧烈腹痛, 面色青紫,恶心、呕吐; ②腹部症状重、腹膜炎症状出现较晚,受伤早期确诊较难; ③多数并发邻近脏器损伤,易漏诊,尤其是腹膜后十二指肠损伤; ④并发症多,易发生十二指肠瘘,处理困难,病死率高; ⑤易伴有胰腺不同程度挫伤; ⑥B超、X线片及CT检查阳性率低,往往在出现腹膜炎体征后才受到重视。在腹部闭合性损伤患者中,出现剧烈腹痛,同时有腰背部触痛,腹部体征轻,应考虑十二指肠损伤; 对于十二指肠腹膜后部分的损伤,腹部体征轻微、腰部体征较重、出现颈部皮下气肿及髂凹炎症者应提高警惕性,故做必要的检查,以便及早诊治。本组10例十二指肠损伤中最早于伤后5 h确诊,最晚25 h才确诊,有的则在剖腹探查中明确诊断。对于十二指肠损伤的治疗,手术修补可靠,需行充分的腹腔引流及有效的胃肠减压,以使损伤后的十二指肠处于空虚状态利于其愈合。围手术期抗感染及静脉营养是挽救患者的关键。对合并有胰腺损伤者,应用抑制胃、胰腺分泌的药物如生长抑素。十二指肠损伤的术式选择应根据受伤部位、大小、程度、类型及全身与局部情况决定: ①单纯肠修补; ②完全断裂者可断端清创后行对端肠吻合; ③肠损伤广泛者,修补后可行十二指肠旷置和引流,加作胃空肠吻合或胃空肠Roux-Y吻合,将十二指肠憩室化; ④合并胰头严重损伤者可选用胰十二指肠切除术,此术创伤重、费时复杂、病死率高,应从严掌握; ⑤对十二指肠壁血肿清除时应注意探查,若有肠黏膜破裂,需彻底止血后予以修补; ⑥修补肠破损时可用空肠浆膜覆盖术或带蒂游离肠壁片移植修补术加强之,以预防肠瘘; ⑦空肠造口术,术后早期可予以肠内营养,有利于早日康复。

    Release date:2016-09-08 10:57 Export PDF Favorites Scan
  • Application of indocyanine green angiography in the selection of implant for breast reconstruction

    ObjectiveTo analyze the value of indocyanine green (ICG) fluorescence imaging in the evaluation of blood flown of ipple-areola complex (NAC) and implant selection during single-port endoscopic breast reconstruction. Methods From November 2018 to March 2020, 19 patients who underwent single-port inflatable endoscopic nipple-sparing mastectomy combined with breast reconstruction in Beijing Friendship Hospital were retrospectively collected. ICG fluorescence imaging technology was used to evaluate the blood supply pattern and the risk of ischemic necrosis of NAC, so as to guide the selection of implant. At the same time, 14 patients who underwent single-port inflatable endoscopic nipple-sparing mastectomy combined with breast reconstruction in Beijing Friendship Hospital from February 2017 to October 2018 were selected as the historical control group (control group). NAC ischemic necrosis, breast satisfaction and implant removal were compared between the two groups. Results In the ICG group, there were3 cases of V1 pattern and 2 cases of NAC ischemic necrosis (1 case of grade 1, 1 case of grade 2). There was no NAC ischemic necrosis in 16 patients with V2 mode and V3 mode. No implant loss occurred in any of the patients. In the control group, 5 cases had NAC ischemic necrosis (all were severe ischemic necrosis), and 2 cases had implant loss. The rate of severe NAC ischemic necrosis in the ICG group was lower than that in the control group (P<0.01), but there was no significant difference in implant loss rate between the two groups (P=0.17). The breast satisfaction score of the ICG group was higher than that of the control group (P<0.01), but there were no significant difference in satisfaction scores of chestwell-being, psychological well-being and sexual well-being between the two groups (P>0.05). Conclusions ICG imaging can be used to evaluate the blood supply pattern during the operation of prosthetic body mass reconstruction, guide the choice of implant in immediate breast reconstruction, so as to further improve postoperative breast satisfaction.

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