经阴道腹腔镜胆囊切除术的临床应用

The clinical application of transvaginal laparoscopic cholecystectomy

目的探讨经阴道腹腔镜胆囊切除术的可行性与安全性。方法对5例于2009～2014年入院的胆囊结石患者行经阴道腹腔镜胆囊切除术。其中3例伴有妇科并发症患者先行阴式子宫全切术,然后经阴道残端放入SILS PORT,其余患者经阴道后穹隆3cm切口安放SILS PORT,三通道内分别插入3个软性器械套管,建立防止漏气的通道,充气后首先于SILS PORT 6点位通道置入腹腔镜,探查腹盆腔情况,并监视硬质弯曲操作器械通过3点及9点位通道到达胆囊区附近。分离钳分离出胆囊管及胆囊动脉,置入钛夹分别夹闭胆囊管及胆囊动脉,常规切除胆囊,电凝胆囊床;经阴道取出胆囊;缝合阴道残端或阴道后穹窿,安置尿管。其中3例患者因腹腔有粘连,为防止对肠管造成损伤,经脐戳孔安置trocar放入腹腔镜监视下放入操作器械。1例合并右肾囊肿者完成胆囊切除后,游离出囊肿,距肾实质0.5cm切除囊壁,残留囊壁适当电凝,检查无出血及胆漏、尿漏,胆囊及囊壁组织经阴道切口取出体外。于脐部辅助戳孔并放置引流管。直视下用可吸收线连续缝合阴道后穹隆切口,安置尿管。结果 5例均无中转开腹。胆囊切除时间27～55min,平均胆囊切除术时间（38.4±10.4）min;肾囊肿切除时间49min,术中平均出血量（28±10.4）ml。术后平均住院时间为（3.8±0.8）d。术后随访6～12个月,全组无出血,无明显腹壁手术瘢痕,无胆漏、尿漏等并发症发生。结论经阴道腹腔镜胆囊切除术安全可行,并可同期治疗多脏器病变,具有临床推广应用价值。

Objective To investigate the feasibility, safety and superiority of natural orifice translumenal （trans- vaginal） endoscopic cholecystectomy. Methods 5 inpatients with cholecystolithiasis were treated with the transvaginal lapatoscopic cholecystectomy during 2009 to 2014. 3 cases with gynecological complications were treated with the vaginal hysterectomy, firstly. Then place single incision laparoscopic surgery port （SILS PORT） through the vaginal residue. The rest of patients placed the SILS PORT through the 3cm incision on the posterior fornix of vagina. Three soft manipu- lator cannulas were inserted in three channels separately to establish the channels against leakage. After inflation, we placed the laparoscope in the abdominal cavity through 6 o＇clock position channel of SILSPORT to check the condition of abdominal cavity and cavitas pelvis and to monitor the curvate manipulator to reach at the cholecyst through the 3 and 9 o ＇clock channels. We separated the cystic duct and cystic artery, and did the occlusion with the titanium clamp separately. Then we did the routine cholecystectomy and electrocoagulation of gallbladder bed. After that, the gallbladder was re- moved out from the vagina. Then the vaginal residue or posterior fornix of vagina was closed. Finally, the catheter placed. The 3 cases with abdominal adhesion were completed by the umbilical auxiliary trocar in order to prevent from in- testinal injury. One case accompanied by the right kidney cyst was dissociated the cyst and cut the wall of the cyst 0.5cm far from the kidney and electrocoagulate the rest of the wall after the cholecystectomy. After checking, if there were hemorrage, bile leakage and urine leakage, we removed the gallbladder and cyst wall from the vagina orifice, then placed the drainage tube. Finally, using the absorbed surgical suture closes the incision on the posterior fornix of vagina under direct vision. Finally place the catheter. Results All of five patients were without laparotomy, bleeding, and bile leakage, urinary leakage and other complications. The gallbladder removal time was 27～55 min. The average time of surgical gallbladder removal was （38.4± 10.4） min. Renal cyst removed at 49min. The average hospitalization time was （3.8±0.8）d. The average amount of bleeding during the operation was （28± 10.4）ml There was no surgical scar on abdominal wall and no abnormality after six-month -to -one-year review. Conclusion Compared with the traditional laparoscopic surgery, transvaginal laparoscopic cholecystectomy is feasible and safe. It has obvious advantages and can do the treatment of multi-organ diseases in the same time.