Laproscopic Cholecystectomy

Laparoscopic cholecystectomy yog ib qho kev phais me me rau kev tshem tawm cov kab mob gallbladder. Qhov tshwm sim ntawm gallstones nce nrog lub hnub nyoog nce, nrog rau cov poj niam feem ntau yuav tsim gallstones dua li txiv neej. Hnub nyoog 50 txog 65 xyoo kwv yees li 20% ntawm cov poj niam thiab 5% ntawm cov txiv neej muaj pob zeb. Zuag qhia tag nrho, 75% ntawm lub gallstones yog tsim los ntawm cov roj (cholesterol), thiab lwm 25% yog pigmented. Txawm hais tias muaj cov kab mob gallstones, cov tsos mob thiab cov tsos mob zoo ib yam.
 

indications

Cholecystitis (Acute / Chronic)

• Cov tsos mob cholelithiasis
• Biliary dyskinesia
• Acalculouscholecystitis
• Gallstone pancreatitis
• Lub gallbladder masses / polyps

Contraindications

• Tsis muaj peev xwm zam pneumoperitoneum lossis kev siv tshuaj loog
• Kev kho tsis tau coagulopathy
• Kab mob metastatic

Teeb meem

Cov teeb meem tshwm sim muaj xws li tab sis tsis txwv rau los ntshav, kis kab mob, thiab kev puas tsuaj rau cov qauv nyob ib puag ncig. Los ntshav yog ib qho teeb meem tshwm sim vim lub siab yog ib yam kab mob vascular heev. Cov kws phais uas muaj kev paub dhau los yuav tsum muaj kev paub txog kev kho mob anatomical anomalies ntawm cov hlab ntsha kom tiv thaiv cov ntshav poob. Qhov teeb meem loj tshaj plaws yog kev raug mob iatrogenic ntawm cov kab mob siab / kab mob siab. Kev raug mob rau ib qho ntawm cov qauv no yuav xav tau kev phais ntxiv kom hloov cov kua tsib mus rau hauv cov hnyuv. Cov txheej txheem no feem ntau yuav tsum muaj tus kws phais neeg mob hepatobiliary tshwj xeeb

Thaum kawg, txawm tias tsis muaj teeb meem, kev hloov pauv mus rau txoj kev qhib tau dhau los ua qhov tshwm sim tsis tshua muaj vim tias kev paub ntawm cov kws phais tau nce ntau xyoo. Kev hloov pauv mus rau qhov txheej txheem qhib ua rau muaj qhov mob plab loj dua, ua rau muaj kev tswj xyuas qhov mob tseem ceeb tom qab kev phais, thiab ua rau lub caws pliav tsis txaus siab. Thov nco ntsoov tias kev hloov pauv mus rau txoj kev qhib yuav tsum tsis txhob saib yog qhov teeb meem tab sis pom tias yog qhov kev txiav txim siab kawm tau zoo los ntawm tus kws phais neeg uas paub txog kev saib xyuas tus neeg mob kom nyab xeeb.
 

Clinical tseem ceeb

Kev phais arthroscopic feem ntau ua rau mob pob qij txha thiab txhav dua li qhib kev phais. Kev rov qab los kuj feem ntau siv sij hawm tsawg dua.

Koj yuav muaj qhov txhab me me uas cov cuab yeej arthroscopic nkag mus rau hauv koj lub cev. Hnub tom qab kev phais, koj tuaj yeem tshem tau cov ntaub qhwv phais thiab hloov lawv nrog cov strips me me los npog qhov incisions. Koj tus kws kho mob yuav tshem tawm cov kab mob uas tsis tuaj yeem tshem tawm tom qab ib lub lim tiam lossis 2.

Thaum koj cov qhov txhab zoo lawm, koj yuav tsum ua kom qhov chaw qhuav li sai tau. Qhov no txhais tau tias npog lawv nrog lub hnab yas thaum koj da dej.

Koj tus kws kho mob yuav qhia koj tias koj yuav tsum tau ua dab tsi thaum koj mus tsev. Koj tuaj yeem rov qab mus ua haujlwm lossis tsev kawm ntawv tsis pub dhau ob peb hnub ntawm kev phais. Tag nrho kev sib koom ua ke rov zoo feem ntau yuav siv sij hawm ntau lub lis piam. Nws yuav siv li ob peb lub hlis kom rov zoo li qub.

Lub etiology ntawm tus kab mob gallbladder yog txuam nrog kev ua haujlwm tsis zoo ntawm lub gallbladder thiab cov kua tsib superconcentrated. Feem ntau, lub gallbladder nteg nws cov ntsiab lus nyob rau hauv teb rau physiologic kev hloov uas cuam tshuam nrog kev zom (cholecystokinin, vagal input los ntawm antral distension, migrating myoelectric complex). Qhov siab ntawm cov roj cholesterol hauv lub gallbladder yog qhov paub ua rau nag lossis daus ntawm cov cholesterol gallstones. Pigmented pob zeb precipitate feem ntau yog los ntawm cov kab mob hemolytic (dub pob zeb) los yog los ntawm kab mob (pob zeb xim av) qhov twg cov kab mob enzymes zom bilirubin rau hauv cov ntsiab lus insoluble. Stasis nyob rau hauv lub gallbladder los yog cov kua tsib ducts tsub kom qhov tshwm sim ntawm pob zeb tsim. Kab mob gallbladder yog piv txwv los ntawm kev cuam tshuam ntawm cystic duct. Cov neeg mob tej zaum yuav muaj kev cuam tshuam ntawm cystic duct los ntawm pob zeb, lossis qee zaus, hauv cov neeg mob hnyav feem ntau, muaj mob acalculouscholecystitis, qhov uas tsis muaj kev cuam tshuam rau txhua yam tab sis muaj kev cuam tshuam. Qhov kev cuam tshuam no, txhua yam lossis tsis yog, nrog rau kev sim ua kom cov kua tsib tso rau kev zom zaub mov yuav ua rau mob hnyav ntawm lub gallbladder.
 

Ib qho kev tshawb nrhiav classic rau kab mob gallbladder yog txoj cai sab sauv lossis mob plab epigastric. Qhov mob feem ntau muaj qhov pib tshwm sim 30 feeb mus rau ob teev tom qab noj cov khoom noj rog. Qhov mob tuaj yeem nyob ntawm ib mus rau ob teev, mus txog ntau tshaj 24 teev. Mob ntev tshaj 24 teev yog txuam nrog kev kis kab mob thib ob hu ua mob cholecystitis. Mob radiates los ntawm sab xis sab sauv mus rau sab xis flank, thiab qee zaus mus rau sab xis ntawm lub xub pwg vim muaj kev sib haum xeeb innervation. Cov tsos mob muaj xws li tab sis tsis txwv rau xeev siab, ntuav (bilious), ua npaws, ua daus no, thiab raws plab. Cov tsos mob tsawg dua tuaj yeem ntsib xws li plab zom mov, cov tsos mob zoo li GERD, cov tsos mob PUD, thiab dyspepsia. Ua ntej ntawm tus txheej txheem tus kab mob, qhov mob yuav tsis cuam tshuam thiab cuam tshuam nrog qhov ncauj noj cov zaub mov rog. Raws li cov txheej txheem nce ntxiv, qhov mob yuav tshwm sim ntau zaus thiab tshwm sim tsis hais qhov ncauj qhov ncauj.
 

Ua kom tiav cov keeb kwm thiab kev kuaj lub cev, suav nrog kev kuaj mob plab, thiab xyuas tshwj xeeb rau "Murphy's Sign."
 

• Murphy's kos npe: sib sib zog nqus palpation nyob rau hauv txoj cai sab sauv quadrant thaum tus neeg mob txhawb siab heev. Qhov kev kuaj pom zoo yog thaum tus neeg mob sai sai nres lawv qhov kev tshoov siab thib ob rau qhov mob [10].
• Labs: Ua kom tiav ntshav suav (CBC) nrog qhov sib txawv (leukocytosis), lub siab ua haujlwm vaj huam sib luag (siab tag nrho bilirubin, alkaline phosphatase, thiab muaj peev xwm ua tau transaminitis), Amylase / Lipase (Qhov siab tuaj yeem qhia tau tus kab mob pancreatitis).
• Kev kos duab:
  • Abdominal ultrasound ntawm txoj cai sab sauv quadrant yuav txheeb xyuas lub xub ntiag ntawm gallstones / sludge / polyps / masses, thickness ntawm lub gallbladder phab ntsa (ib txwm txwv tsawg dua 3 hli), dav ntawm cov kua tsib duct (ib txwm txwv tsawg dua 6 hli, li cas los xij, 1. mm yuav muab ntxiv rau ib xyoo caum ntawm lub neej tom qab 50 xyoo los yog nyob rau hauv cov poj niam cev xeeb tub), thiab muaj/tsis muaj pericholecystic kua.
  • Sib nqus resonance cholangiopancreatography (MRCP): MRI imaging txoj kev tshawb fawb rau cov tsis pom kev pom ntawm biliary thiab pancreatic ducts
  • Endoscopic Retrograde Cholangiopancreatography (ERCP): ib qho kev cuam tshuam endoscopic yog siv x-rays thiab zas xim kom pom cov biliary thiab pancreatic ducts. Qhov zoo ntawm ERCP yog tias nws yog ob qho tib si kuaj thiab kho. Txawm li cas los xij, qhov no yog tus txheej txheem invasive thiab tuaj nrog cov txheej txheem txaus ntshai
  • Hepatobiliary Iminodiacetic Acid (HIDA) Kev Tshawb Fawb: Kev tshawb xyuas duab kom pom daim siab, lub zais zis, thiab cov kua tsib. Cov kab mob radioactive yog txhaj rau hauv cov hlab ntsha, txuas nrog cov kua tsib substrates, thiab ua tiav los ntawm daim siab. Lub tshuab kuaj kab mob nuclear tom qab ntawd taug qab qhov ntws ntawm cov kab mob los ntawm lub siab, mus rau hauv cov kua tsib, lub gallbladder, thiab mus rau duodenum. Qhov sib ntxiv ntawm cholecystokinin, CCK, thaum tsis muaj gallstones yog qhov tseem ceeb rau kev kuaj mob acalculouscholecystitis. Qhov ntsuas ejection feem tsawg dua 35% feem ntau yog qhov qhia tau tias lub zais zis ua haujlwm tsis zoo. Kev tsim tawm ntawm cov tsos mob nrog kev tswj hwm ntawm cholecystokinin kuj tau pom los kwv yees kev daws teeb meem ntawm cov tsos mob tom qab cholecystectomy. Cholecystokinin yuav tsum tsis txhob noj nyob rau hauv lub xub ntiag ntawm gallstones vim qhov no tej zaum yuav provoke cov pob zeb mus rau hauv cov kua tsib duct.