| 摘要 |
Laparoscopic cholecystectomy has become the preferred choice of surgical procedure for uncomplicated cholecystolithiasis. With the advances in techniques and instruments, procedures for difficult laparoscopic cholecystectomy have been improved. Between December 1990 and June 1995, 825 cases of laparoscopic cholecystectomy were performed at National Taiwan University Hospital; 548 of those received surgery by the same operative team. Among those patients, 12 had received subtotal or total gastrectomy several years previously. According to experience here the key points of operation for post-gastrectomic patients are: (1) A mini-laparotomy beginning from the right inferior margin of the umbilicus made to facilitate entry of the first trocha and avoid hollow organ injury from adhesion after the previous operation. (2) Insertion of a mid-clavicular port and anterior axillary port for dissection of adhesions beneath the previous operation wound; then the upper midline port can safely be placed under laparoscopic vision. (3) Initial dissection made along both the gallbladder margins until arriving at the junction with the cystic duct. (4) If the cystic duct was not exposed properly, the base of the gallbladder adjacent to the Hartmann’s pouch was taken off the liver bed to facilitate identifying the cystic duct. (5) During operation, manipulation should keep away from the round ligament area to avoid injury to the common blie duct. (6) The gallbladder can be removed from the abdominal cavity through mini-laparotomic region. (7) Closure of the fascia of the mini-laparotomic region avoids ventral herniation, postoperatively. The operation time in these cases ranged from 51 to 247 minutes, with a mean of 111 minutes. The postoperative hospital stay ranged from one to seven days, with a mean of 3.3 days. Postoperative feeding time ranged from 6 hours to 48 hours, with average of 17 .5 hours. In conclusion, it appears that, although adhesiolysis and identification of the anatomic structure are time-consuming, laparoscopic cholecystectomy is feasible and safe for a well-rained surgeon. For the patient’s sake, these procedures are well worth the effort. |
