Chapter 248 244. Acute gangrene cholecystitis

Except for Kavi, no one knows why Rogo Moralian performs this operation.

Surgery requires surgical indications, and also requires technical support to complete this surgery. The gallbladder resection has undergone a "cannot be cut, can be cut, can be cut without cutting stones, cutting it if there is symptoms, and a laparoscopic can be cut.

The bumpy process of laparoscopic cutting.

Nowadays, the indication of gallbladder slicing is a symptomatic patient with gallbladder stones (only the symptoms are cut), not in the past (cut it if there is stones).

But there are exceptions. For example, patients live in remote areas with poor medical conditions. There are gallbladder stones that can be considered for preventive gallbladder resection. The medical conditions of the 19th century are definitely not good. Patients like Rogaro do have to surgical resection as soon as possible as soon as possible.

gallbladder.

Rogaro is a typical symptom. The upper abdomen is severe pain. The tenderness and reflection pain are obvious. There are Murphy signs. The body temperature is 39 ° C. Basically, it can be determined that it is cholecystitis.

Even if Kavi's diagnosis has an error, high -heat abdominal pain needs to be performed as soon as possible, so no matter how surgery is, it will not be wrong.

"Gallbladder surgery is basically removed, because there are a lot of stones in it, and acute inflammation can easily become chronic. It is not wise to retain the gallbladder."

Kavi originally wanted to take the middle incision of the abdomen, but the self -confidence of the diagnosis still made him take the most commonly used right ribs under the ribs of gallbladder surgery: "I have said the symptoms and surgical indications of cholecystitis on the road.

Selection of the incision of gallbladder. "

Herman split the hook to Damilgang and Beckett. One person led the skin and subcutaneous tissue, and the other person opened the right upper abdomen ribs.

He was doing the assistant's work, thinking about this new operation, and soon had a question that he had after his independent thinking: "If it is just stones, can you cut the gallbladder and take it away.

Wash it again, wait for the cleansing, then stitch the gallbladder? "

This is a good proposal. At least in the early days of modern general surgery, there is indeed a point of view. Even at the end of the 20th century, surgical technology has developed to a certain height, and some people have made similar views.

Unfortunately, the large sample data of evidence -based medicine followed by modern medicine resolved controversy.

"No need, just cut it directly." Kavi changed to the surgical attitude that often focused on refined operations, and directly denied this view.

Herman's idea is limited to the abdominal anatomy of the 19th century, which is very similar to Donalson and Ignatz: "The anatomy around the gallbladder is very messy, and removal can easily cause operational errors.

"

Kavi knocked on the tissue pliers in his hand with his own needle, reminding: "The proposal is good, but this is my surgery, so I said it."

".yes."

"If you feel that the gallbladder is not removed well, you can deal with such patients in person." Kavi didn't blame him, "but I think you should dispel such thoughts after entering the abdominal cavity."

Herman couldn't understand what he meant. It wasn't until the incision went down, opened the section all the way, and saw and gently turned the liver dirty noodles before gradually realizing the seriousness of the problem.

"Give me a organ hook." Kavana's hook given by the nurse helped to hold the liver, raised slightly, and said, "Did you see the tissue structure below the liver?"

"See."

"Can you see clearly?"

"cannot."

"I said when I did appendicitis resection before that inflammation stimulated the adhesion of surrounding tissue. It was very difficult to distinguish adhesion.

Kavi looked at the chaotic gallbladder triangle and surrounding purulent liquid, and felt bad: "The large omentum is wrapped in, and the yellow -green liquid can be seen around."

"These are pus?"

"Maybe."

Kavi slowly separates these adhesive tissues with tissue clamps, and the movements are becoming more and more cautious: "The adhesive parts we must deal with first are not liver and gallbladder, but the colon and liver song under the liver and gallbladder.

To carefully separate the basic hand speed without damage to the surrounding tissue. "

Separate tissue above the colon liver tissue from the colon liver song, usually separated from the second section of the duodenum and the head of the pancreas. Then place the wet gauze on the gallbladder and the horizontal colon, and then the transverse colon is directed to

Pulling below to expose the neck of the gallbladder. [1]

However, just a part of the gallbladder that was exposed has surprised them, which is completely different from the gallbladder they saw during the anatomy of their usual corpses.

Kavi touched the gallbladder wall gently with tissue pliers, saying: "Severe adhesion, high epidermis tension, increased shape, and crispy texture, typical gangrene gallbladder

The leakage, the pus in it poured out, the consequences were unimaginable. ""

"What will happen?"

"Similar to acute peritonitis, a shock will eventually appear."

The gallbladder is visible to the naked eye, and the surrounding tissue is tightly wrapped. Even the easiest tissue around the gallbladder is not separated, the most important gallbladder triangle is even more troublesome.

And bile ducts, everyone is terrible, it will greatly affect the prognosis of the surgery.

Ordinary gallbladder resection will simply pull the gallbladder itself.

For example, you can clamp the belly of the gallbladder pot, pull the head and side of the head, and then open the liver duodenal intestinal plasma layer, so that the anatomical relationship between the liver door can be clear. [2]

But now the gallbladder texture cannot be banned at all. If you do n’t break it, you are grateful. How to separate it?

Kavi put down the tissue pliers, suspended the original gallbladder removal, and changed the idea. Since the biliary cysts are severe, and they are afraid that it will be ulcerated.

Give me a syringe. "

The syringe was pierced into the gallbladder bottom [3], slowly pulled out 4ml pus, the tension of the gallbladder became smaller, and Cavi also found two key points from the puncture.

First, the gallbladder wall was found during puncture, and it should be more than 4mm. This is caused by hyperplasia after the stimulation of cholecycle inflammation.

stone.

Based on these two points, the separation of Kavi became bold: "If it is ordinary gallbladder stones, the increase in volume of the gallbladder is not obvious, we may be able to do the anatomy of the gallbladder triangle first.

But now the gallbladder triangle anatomy is chaotic, it is more reliable to separate the gallbladder first, and it also provides more vision for the gallbladder triangle of the gallbladder. "

Speaking of vision, he changed the position of the candlestick in Bergt's hand: "Now we continue to separate the tissue around the gallbladder and separate the gallbladder from the liver gallbladder bed as soon as possible.

Kavi's preparation is very timely.

Because gallbladder that increases the increase in gangrenes will closely fit with the liver, bleeding of separation wounds often occurs during separation. And this bleeding often has a large amount, and the suture of ordinary needle wires can not work.

Modern surgery will choose medical hemostatic gels and hematopoietic gauze, and only the posterior pyramids can be used in Kavi's hands.

Dipping away, bleeding, burning and stopping bleeding.

Dipping away, bleeding, stop bleeding

The separation of the gallbladder has spent more than 20 minutes. Basically, it is equivalent to the speed of coming to power before. Considering the current conditions, it can be said that it is extraordinary. But this is not enough. The most ideal surgery time should not exceed 50 minutes.

It was over at the first ether anesthesia.

"The gallbladder is separated, we put it temporarily, and began to separate down the gallbladder triangle."

Because the gallbladder decompression just now, the gallbladder wall is also very thick. As long as it is well protected, carefully pulling the gallbladder will not cause the gallbladder to break: "Heman gently pulls the tissue pliers, yes, outward, and out, don't be too hard, don't be too hard, don't be too hard, don’t be too hard to force it too hard, don't be too hard to force it too hard, don't be too forceful

Okay! Keep this! "

When separation, you first need to open the liver duodenum intestinal ligament pulp membrane layer to clarify the anatomical relationship in the liver door. [4]

Cavi quickly saw the gallbladder tube, and used the silk thread to make a dual ligation, and then said: "Doing dual ligation is to prevent the mud in the gallbladder squeezed into the gallbladder tube into the gallbladder tube during surgical operations.

Causes unnecessary obstruction. "

"Where is the gallbladder arteries?" Herman looked a little flowers, and he couldn't figure out the location relationship inside the gallbladder triangle.

"You have to continue the anatomy slowly." Kavi carefully flipped the surrounding connective tissue and said, "The gallbladder arteries are derived from the total hepatic arteries and may also be derived from the right hepatic arteries.

Differential structure of biliary tract and arteries, avoid unnecessary tissue structure of damage. "

In fact, in addition to these two categories, there are many special variations, which is also an important factor in the trouble of the triangle of the gallbladder.

For example, from the left artery of the liver, or the occurrence of double gallbladder arteries from the left and right arteries of the liver, etc. [5]

Fortunately, Rogaro's gallbladder arteries are not troublesome. The starting position is a very standard hepatic right artery. But this does not prove that the anatomical anatomical is easy. Before the liver of the liver enters the liver essence, the gallbladder canal and gallbladder will be

Accompanying, it is easy to be mistaken for the gallbladder arteries, causing a mistake to ligate.

"So, no matter what the situation is, the gallbladder arteries should be clearly dissected, and it must be clear that it does enter the gallbladder before you can ligrate."

Kavi's anatomy is very detailed, but the speed of hand is not slow. The triangle of the gallbladder in front of everyone has gradually become clear, and the gallbladder arteries slowly emerge from his movement path.

"Generally, gallbladder arteries are on the surface of the gallbladder, and then enter the gallbladder vertically."

Kavi changed the direction of gallbladder pulling, revealing more cholecoscopic triangle anatomical areas, and the movement of gallbladder arteries became clearer: "First give me a set of stitches and silk threads, and then prepare two of the same sets. I want I want

Make a triple ligation. "

Olatinum resection is not a particularly troublesome surgery. It is also one of the surgical styles that Kavi hopes to give them to them as soon as possible.

Difficulty and popularity should be as cesarean section. The resection of appendicitis is equivalent.

However, one of this kind of troubles of duck -filled teaching is that many details are difficult to master, and it must be emphasized to strengthen their memory. Therefore, in the gap between lust, Kavi once again emphasized to understand the key to understanding the gallbladder triangle and ligments of gallbladder arteries.

point.

"I want to repeatedly emphasize that the oats and the gallbladder triangle is very, very important, and must be completely exposed to the gallbladder arteries, otherwise the gallbladder arteries should not be ligated. In this case, it needs to be repeatedly confirmed to judge. Don't be irritable.

patience."

After the blood vessels were separated, Kavi was separated from the pliers of the gallbladder tube. The huge gallbladder was removed from Rogaro's abdominal cavity.

"Physiological saline, quickly rinse the abdominal cavity."

"How many times?"

"Let's go three times first, rinse carefully, especially the area where the surgery just now has a lot of pus and bleeding."

"I understand this."

Bergrt poured the physiological saline in the metal basin into the abdominal cavity.

"Well, put two drainage tubes under the liver after cleaning."

"OK"

Carve puts the gallbladder with dark and enlarged gallbladder, and cut it gently with scissors. The mule is separated from the gallbladder wall, exposing a lot of gallbladder stones inside: "Do a record, 'Remove huge gangrene gallbladder, size 9*8

*3cm, there are a lot of sediment stones in the gallbladder after cutting, the largest stone diameter of 3cm. "

[Mother -in -law is gone, pulmonary hypertension, right heart failure for nearly 20 years, has been dragging for a long time. I have been a bit busy recently, I still recommend you to keep fatter]
Chapter completed!