目的:探讨急性阑尾炎行腹腔镜阑尾切除术的手术方法与技巧,及其临床应用价值。方法:我院自2021年1月至2022年5月收治的165例急性阑尾炎患者行腹腔镜阑尾切除术,结合患者相关临床资料总结临床经验。结果:所有患者均顺利完成手术,无中转开腹,术后康复出院。手术时间20~80 min,出血量2~30 ml,住院时间3~7 d。术后切口感染2例,盆腔积液2例,均保守治疗痊愈,未出现阑尾残端瘘、盆腔积脓、门静脉炎等严重并发症,术后随访6月,无远期并发症。结论:术前应尽量完善各项检查,明确腹腔及阑尾情况,做到术前心中有数;术者及助手应熟练掌握腹腔镜技术,清楚了解阑尾系统解剖及病理改变,操作时配合默契,总结手术各个步骤细节并完善手术技巧,为急性阑尾炎患者行腹腔镜阑尾切除术是安全可行的,并且能够缩短手术时间,减少手术并发症的发生。 Objective: To investigate the surgical methods and techniques of laparoscopic appendectomy for acute appendicitis and its clinical application value. Methods: 165 patients with acute appendicitis in our hospital from January 2021 to May 2022 underwent laparoscopic appendectomy. Combined with the relevant clinical data, the clinical experience was summarized. Results: All patients successfully completed the operation, with no conversion to open surgery, postoperative recovery and discharge. The operation time was 20~80 min, the blood loss was 2~30 ml, and the hospital stay was 3~7 d. Postoperative incision infection in 2 cases and pelvic effusion in 2 cases were cured by conservative treatment, and there were no serious complications, such as appendiceal stump fistula, pelvic abscess, and portal phlebitis. Postoperative follow-up for 6 months showed no long-term complications. Conclusion: Preoperative examinations should be improved as far as possible to clarify the conditions of abdominal cavity and appendix, so as to have a clear idea before surgery. Operators and assistants should master laparoscopic techniques, have a clear understanding of the anatomy and pathological changes of the appendix, cooperate with each other in operation, summarize the details of each surgical step and improve surgical skills. Laparoscopic appendectomy for patients with acute appendicitis is safe and feasible, and can shorten the operation time and reduce the occurrence of surgical complications.
目的:探讨急性阑尾炎行腹腔镜阑尾切除术的手术方法与技巧,及其临床应用价值。方法:我院自2021年1月至2022年5月收治的165例急性阑尾炎患者行腹腔镜阑尾切除术,结合患者相关临床资料总结临床经验。结果:所有患者均顺利完成手术,无中转开腹,术后康复出院。手术时间20~80 min,出血量2~30 ml,住院时间3~7 d。术后切口感染2例,盆腔积液2例,均保守治疗痊愈,未出现阑尾残端瘘、盆腔积脓、门静脉炎等严重并发症,术后随访6月,无远期并发症。结论:术前应尽量完善各项检查,明确腹腔及阑尾情况,做到术前心中有数;术者及助手应熟练掌握腹腔镜技术,清楚了解阑尾系统解剖及病理改变,操作时配合默契,总结手术各个步骤细节并完善手术技巧,为急性阑尾炎患者行腹腔镜阑尾切除术是安全可行的,并且能够缩短手术时间,减少手术并发症的发生。
腹腔镜,阑尾切除术,急性阑尾炎
Limin Liu*, Baijiang Wan, Zhuo Liu, Yue Zhao, Zongming Zhang
Department of General Surgery, Beijing Electric Power Hospital, State Grid Corporation of China, Beijing
Received: Aug. 8th, 2023; accepted: Sep. 19th, 2023; published: Sep. 26th, 2023
Objective: To investigate the surgical methods and techniques of laparoscopic appendectomy for acute appendicitis and its clinical application value. Methods: 165 patients with acute appendicitis in our hospital from January 2021 to May 2022 underwent laparoscopic appendectomy. Combined with the relevant clinical data, the clinical experience was summarized. Results: All patients successfully completed the operation, with no conversion to open surgery, postoperative recovery and discharge. The operation time was 20~80 min, the blood loss was 2~30 ml, and the hospital stay was 3~7 d. Postoperative incision infection in 2 cases and pelvic effusion in 2 cases were cured by conservative treatment, and there were no serious complications, such as appendiceal stump fistula, pelvic abscess, and portal phlebitis. Postoperative follow-up for 6 months showed no long-term complications. Conclusion: Preoperative examinations should be improved as far as possible to clarify the conditions of abdominal cavity and appendix, so as to have a clear idea before surgery. Operators and assistants should master laparoscopic techniques, have a clear understanding of the anatomy and pathological changes of the appendix, cooperate with each other in operation, summarize the details of each surgical step and improve surgical skills. Laparoscopic appendectomy for patients with acute appendicitis is safe and feasible, and can shorten the operation time and reduce the occurrence of surgical complications.
Keywords:Laparoscopy, Appendectomy, Acute Appendicitis
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随着腹腔镜操作技术的发展与成熟、临床经验的积累及设备的进一步完善,腹腔镜阑尾切除术适应证已在不知不觉中逐渐扩大,原来属于相对禁忌证的病症,现也已逐步放宽为适应证。作者总结性地回顾分析了2021年1月至2022年5月为165例急性阑尾炎患者成功施行腹腔镜阑尾切除术的临床经验与体会。现将结果报道如下。
本组共有阑尾炎患者165例,其中男性78例,女性87例。年龄18~83岁,平均44.1 ± 15.0岁。急性单纯性阑尾炎14例,急性化脓性阑尾炎98例,急性坏疽性阑尾炎36例,急性坏疽性阑尾炎伴穿孔17例。临床表现:转移性右下腹痛,恶心呕吐,发热寒战,腹泻等症状。体格检查:右下腹麦氏点压痛阳性,伴反跳痛及肌紧张,右下腹包块。入组标准:术前诊断急性阑尾炎明确,心肺功能正常,能耐受全麻和气腹。排除标准:合并严重心肺功能衰竭不能耐受全麻者。
患者平卧位,气管插管全麻,显示器位于患者右侧,主刀及一助手位于患者左侧。术区常规消毒铺巾,采用三孔法,脐上10 mm Trocar为腹腔镜观察孔,另外两处5 mm Trocar分别位于脐与耻骨联合中点及平脐右腹直肌外缘处。建立气腹后进行探查,如有较多脓液需先吸出脓液后,再取头低15~20度,右高15~20度,分离右下腹大网膜及小肠与结肠间炎性粘连,顺结肠带找到阑尾,确认阑尾根部。紧贴阑尾切断系膜,应用电刀或超声刀使用“防波堤”凝闭技术切断阑尾系膜,减少术中及术后出血,暴露以阑尾根部为中心1~2 cm盲肠壁,方便阑尾根部荷包包埋。用7号丝线在阑尾根部结扎,距离结扎线0.3~0.5 cm处切断阑尾。常规3-0用可吸收线缝合荷包闭合包埋阑尾残端。如阑尾根部坏疽严重或盲肠水肿严重无法包埋者用7号线双重结扎,并将大网膜覆盖于阑尾残端。阑尾经脐上Trocar取出,如阑尾直径超过10 mm,用标本袋取出。将腹盆腔脓性渗出液吸净,并用纱布蘸干,如脓液达肝周需用生理盐水冲洗并留置引流管。5 mm Trocar切口皮下组织不缝合,皮肤用胶水粘合,10 mm Trocar切口用1-0可吸收线缝合白线,3-0可吸收线缝合皮下组织,皮肤用胶水粘合。
所有患者均顺利完成手术,康复出院。手术时间20~80 min,平均42.3 ± 13.4 min。出血量2~30 ml,平均7.5 ± 4.5 ml。住院时间3~7 d,平均5.4 ± 1.6 d。并发症:切口感染2例,盆腔积液2例,均保守治疗痊愈。术后随访6月,无腹膜炎、阑尾残端瘘及切口疝发生。
急性阑尾炎是临床最常见的腹部外科急腹症之一,个体一生中发生阑尾炎的概率为7~8% [
尹克宁等报道单孔腹腔镜阑尾切除术治疗急性阑尾炎术后患者疼痛较轻,切口更美观。但手术操作困难且时间长,不适合病情复杂及严重阑尾炎病例 [
急性阑尾炎患者腹腔多有粘连,我们选用三孔法,且脐缘穿刺孔均选在脐上缘,其好处在于随着腹腔镜的推进腹腔观察的范围较下缘扩大,3个操作孔可以互相协调,更便于暴露、分离粘连。两操作孔在回盲部两侧,方便阑尾的显露,尤其是盲肠后位阑尾及阑尾周围脓肿患者,有利于术中打结与缝合。两操作孔选用5 mm Trocar,对腹壁损伤小,术后皮下组织不用缝合,皮肤用生物胶粘合即可,减轻术后疼痛,减少手术时间,瘢痕反应轻。
阑尾系膜的处理常见方法有丝线结扎法、电凝法、超声刀法及结扎夹法、圈套器套扎法、切割闭合器切割闭合法等 [
阑尾动脉位于阑尾系膜的边缘,如在根部结扎系膜,容易导致出血,因为靠近阑尾处阑尾系膜内血管较细小,我们推荐紧贴阑尾应用电凝法切断系膜,这样可以减少术中出血及术后出血风险,降低手术成本。而且阑尾炎时阑尾系膜肥厚,紧贴阑尾切断系膜利于标本取出,缩短手术时间。
阑尾炎术后阑尾残端瘘是严重并发症,所以如何安全有效地处理阑尾根部至关重要。阑尾根部的处理方法临床报道较多,主要包括单纯丝线结扎法、钛夹夹闭法、Hem-o-lok夹闭法、可吸收夹夹闭法、圈套器套扎法、切割闭合器切割闭合法等 [
钛夹、Hem-o-lok及可吸收夹处理阑尾根部具有简单易学的特点,但阑尾炎症时组织变脆,阑尾增粗,使用夹子夹闭阑尾不能调节结扎力度,容易导致夹闭不全或组织切割,出现阑尾残端瘘的风险。圈套器处理阑尾根部操作简单,力度可调整,但与丝线结扎相比价格较高。切割闭合器用于阑尾根部异常粗大或者坏死无法结扎与缝扎患者,价格昂贵,临床应用较少。丝线结扎阑尾根部受力均匀,不残留异物,价格低廉 [
阑尾根部应用丝线结扎后进行荷包缝合,对于不熟练者来说费时费力,熟练后阑尾根部结扎及包埋时间我们可控制在3分钟内,并不增加手术时间。而且不残留异物,降低手术费用,同时为初学者提供了一个很好的提高体内打结技术的机会。荷包缝合顺序与技巧,建议逆时针方向从盲肠前壁结肠带开始的顺序,在距阑尾根部约1 cm的盲肠壁上行四针浆肌层缝合,完成一圈荷包缝合。这样四针均可以正缝,操作比较顺手,并且缝合完毕后线结打在盲肠前壁,方便阑尾残端的包埋与打结。对于阑尾根部坏疽穿孔导致阑尾根部无法结扎及荷包包埋患者,我们推荐行“8”字缝合或“U”行缝合,并大网膜覆盖阑尾根部 [
腹腔镜直视下操作,相比于开腹手术,可以将脓液清理得更加彻底,降低了腹腔脓肿风险,引流管的放置比例呈下降趋势 [
阑尾可经脐上Trocar取出,避免污染切口,减少术后切口感染风险。具体方法是用右侧腹操作孔夹住阑尾断端,在腹腔镜导向下将阑尾置入脐上Trocar后取出。如果阑尾较粗大,无法直接经Trocar取出,可将阑尾置入标本袋后经脐上切口取出 [
总之,对急性阑尾炎患者行腹腔镜阑尾切除术是安全有效的,对于坏疽穿孔阑尾炎及阑尾周围脓肿同样是安全有效的,只要熟练掌握腹腔镜技术,清楚了解阑尾系统解剖及病理改变,操作时配合默契,总结手术各个步骤细节并完善手术技巧,就能够缩短手术时间,减少手术并发症的发生,降低患者痛苦及创伤,促进快速康复。
刘立民,万柏江,刘 卓,赵 月,张宗明. 165例急性阑尾炎行腹腔镜阑尾切除术的临床体会Clinical Experience of Laparoscopic Appendectomy in 165 Cases of Acute Appendicitis[J]. 外科, 2023, 12(04): 28-32. https://doi.org/10.12677/HJS.2023.124005
https://doi.org/10.1002/bjs.9329
https://doi.org/10.1186/s13017-023-00507-6