胆囊切除手术流程

胆囊切除手术 胆囊切除手术 一、 胆囊切除术简介 1.胆囊切除术 胆囊切除术是胆道外科常用的手术。分顺行性(由胆囊管开始)切除和逆行性(由胆囊底部开始)切除两种。顺行性胆囊切除，出血较少，手术简便，应优先采用。但在炎症严重，胆囊与周围器官紧密粘连，不易显露胆囊管及胆囊动脉时，则以采用逆行性切除法为宜。有时则需两者结合进行。 2.胆囊 胆囊位于腹部的右侧，借疏松结缔组织 附于肝脏下面(脏面)的胆囊窝内，是呈梨 形的囊状器官，分底、体、颈、管四部。胆 囊储存和浓缩肝脏产生的胆汁，并把胆汁输 送到十二指肠，帮助脂肪消化。胆汁从胆囊 经胆囊管及胆总管排入十二指肠内。 胆囊底为突向前下方的盲端，常在肝下缘露出，其体投影相当于右侧腹直肌外侧缘与右肋弓相交处，当胆囊发炎时此处可有压痛。 胆囊体部向前上弯曲变窄形成胆囊颈，颈上部呈囊性膨大，称Hartmann囊，常是胆囊结石滞留的部位。胆囊管由胆囊颈延伸形成，呈锐角与肝总管汇合成胆总管。 胆囊管、胆总管和肝的脏面之间的三角区域称为胆囊三角。胆囊三角内有胆囊动脉、肝右动脉、副右肝管穿行，是胆道手术易误伤的for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet 部位。 二、指征 1、胆总管触到结石; 2、曾有梗阻性黄疸史; 3、胆总管显著扩张; 4、术中造影显示胆管有结石。 三、适应症 1.急性化脓性、坏疽性、穿孔性胆囊炎。 2.慢性胆囊炎，反复发作，内科治疗无效。 3.胆囊结石。 4.慢性萎缩性胆囊炎，胆囊无功能。 5.胆囊良性肿瘤、息肉。 6.胆囊恶性肿瘤。 7.胆囊管发生病变，胆囊排空障碍症状较重患者。 8.Oddi括约肌切开、成形术需同时切除胆囊。 四、胆囊切除术手术流程 [术前准备] 1.慢性胆囊疾病患者，多存在消化不良、营养不良、贫血，故术前应予以纠正:?给予高蛋白、高热量食物;?静脉输血;?补充维生素B、C、K等。 2.急性胆囊炎患者，合并水、电解质、酸碱平衡紊乱者，术前予以纠正:?给予晶体、胶体，持续血容量;?给予大剂量、广谱抗生for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet 素，以控制存在的感染。 3(患者:术前一天护士向患者及家属详细讲解手术室的环境、手术过程术中体位的配合，简单介绍麻醉知识，耐心解释患者提出的疑问，使患者感到安全与信任，告诉患者术日晨勿喝水，换好病号服并系好腕带，并嘱咐患者勿携带金属物品入手术室，有假牙者应去掉假牙，如有必要携带影像学资料。 4.环境:手术室内宽敞明亮，干净整齐。手术间无影灯、手术床、器械车、壁柜表面及地面应在手术前用清水、消毒液各擦一次。 铺好手术床，打开照明灯、无影灯和观片灯，连接好吸引器和吸氧装置，套好黄色垃圾袋。 5.手术用品:衣服包，敷料包，消毒缸，纱布，胆囊切除器械，肝脏拉钩，剖腹包，电刀，20#刀片，剖腹针，1、4、7号线，吸引器，吸引器皮条，吸引器头，切口敷贴，切口膜，一次性无菌手套，20ml注射器，引流管，引流袋。 6.术前插胃管。 7.手术区备皮。 [麻醉] 硬膜外麻醉:患者侧卧?准备好气管插管装置、给氧设备及其他急救用品(防治全脊麻)?严格消毒(患者、术者)?于第8-9胸椎棘突间隙(两侧肩胛骨下角连线平第七胸椎棘突，向下即可找到第8、 )进行旁入法穿刺，注入局麻药物利多卡因。 9胸椎 [体位] for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet 麻醉生效后，患者平卧位，右腰部加垫以充分显露右上腹部。 [手术步骤] 1.术者洗手消毒: 先用肥皂及清水将手臂按普通洗手方法清洗一遍，再用消毒过的毛刷蘸肥皂水(或肥皂)，顺序交替刷洗双手臂，从手指尖至肘上l0cm处，特别注重甲缘、甲沟、指蹼、手掌侧等部位。一次洗刷3分钟后，手指向上，肘部屈曲朝下，使清水从上而下冲净手臂上的肥皂水。如此反复刷洗3遍，共约l0分钟。用无菌毛巾从手向肘部顺序拭干，然后将双手、前臂至肘上6cm处浸泡于70,酒精或0.1,新洁尔灭溶液中5分钟，浸泡时用泡手桶内的小毛巾反复轻轻擦拭手及前臂，最后屈肘将手举于胸前(双手勿低于肘、高于肩为度)，晾干。洗手消毒后，穿手术衣、戴无菌手套。 2.患者手术区皮肤消毒: 手术区皮肤消毒应由助手在手、臂消毒后，尚未穿手术衣和戴手套之前进行。(消毒范围:上至两乳头连线，下至耻骨联合两侧至腋中线。消毒液:可采用0.5,~1,碘伏、0.5,洗必泰碘、2,碘酊、75,乙醇等)。 (1)助手从器械护士手中接过盛有浸蘸消毒液纱球的消毒弯盘与敷料钳。 (2)第一遍消毒由手术区中心开始，向周围皮肤无遗漏地涂布消毒液，注意消毒液不能浸蘸过多，以免引起周围皮肤粘膜的刺激与损伤。 (3)待第一遍消毒液晾干后，换敷料钳以同样方式涂布消毒液一for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet 遍，为第二遍消毒。 (5)手不可碰到手术区。皮肤消毒完毕，铺无菌巾单。铺无菌巾时，用四块无菌巾，每块的一边双折少许，在切口每侧铺盖一块无菌巾，盖住手术切口周围。通常先铺操作者的对面，或铺相对不洁区(如下腹部，会阴部)，最后铺靠近操作者的一侧，并用布巾钳将交角处夹住，以防止移动。无菌巾铺下后，不可随便移动，如果位置不准确，只能由手术区向外移，而不应向内移动。 然后双手再浸泡于洗手消毒液中3分钟。 2.切口:选右肋缘下斜切口?皮肤、浅筋膜、腹直肌鞘、腹直肌、腹膜外组织、壁腹膜。 3.探查与显露:进入腹腔以后，首先探查胆囊，看其位置、大小、颜色，有无穿孔，与周围脏器如十二指肠、横结肠、胃窦部有无粘连，扪查其内有无结石。然后左手食指伸入网膜孔扪查胆总管的情况，看其内有无结石。之后再探查胃、十二指肠、胰腺和肝脏有无病变。 探查完毕以后，取2把中号止血钳，一把夹住胆囊底，一把夹住肝圆韧带，用适当力量向下牵拉，可将肝圆韧带切断。 于胆囊底部用1号线将肌层缝一小荷包，于此荷包中穿刺，将胆汁抽出，使胆囊的体积缩小，结扎荷包。提起胆囊底，用纱布垫将横结肠盖住并向下拉，使胆囊暴露出来。如果胆囊和十二指肠之间有粘连，可用剪刀剪开，直至胆囊壁附近的无血管处，将胆囊将十二指肠之间的粘连完全分开。 用纱布垫将胃和横结肠盖住并用S状拉钩将其向下拉开，使胆囊for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet 与胃、横结肠隔开。网膜孔部位放一块纱布，此时可以进一步探查胆总管，左手食指伸入网膜孔，拇指在外，两指对捏探查胆总管内有无结石，十二指肠乳头部位有无病变，同时探查胰头处有无病变存在。 4.切除胆囊:胆囊切除通常有两种方法，一种是从胆囊管开始的胆囊切除术，另一种是从胆囊底开始的胆囊切除术。前一种方法是先处理胆囊管和胆囊动脉，后剥离胆囊，具有解剖清楚、出血少的优点，为一般常用方法。后一种方法是先剥离胆囊，后处理胆囊管和胆囊动脉，这种方法手术时出血较多，易致手术视野模糊，分离胆囊管和胆囊动脉时较难。 ?从胆囊管开始的胆囊切除术: 取中号止血钳夹住胆囊颈上提，注意勿盲目钳夹以免损伤胆总管。 ? 用刀尖从胆囊体右侧中部划开浆膜，一般切口距肝脏1cm左右。 ? 向下剪开浆膜，并将肝十二指肠韧带切开，用止血钳将浆膜向两侧分离，夹住胆囊颈上提，小心、仔细地用纱布钝性分离胆囊管，用胆囊钳继续分离胆囊管的后壁，要注意辨认胆总管和肝总管，以免误扎。将胆囊管完全分离出来。 ? 取2把中号止血钳，一把距胆总管0.3,0.5cm处将胆囊管夹住，于其远侧再夹一把止血钳，在两钳之间将胆囊管切断。 ? for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet 残端先用7号线结扎，之后再用4号线贯穿缝扎，以防线结脱落，胆汁外漏。 ? 继续向深部分离，可以找到胆囊三角区的另一重要结构——胆囊动脉，继续分离动脉周围的结缔组织，将其完全游离出来，并同时解剖出肝右动脉，进一步明确二者的关系，尽可能靠近胆囊将胆囊动脉夹住，于两钳之间将其切断，残端用7号线结扎，并用4号线缝扎。 ? 胆囊动脉、胆囊管处理完以后，用尖刀距肝1cm的胆囊浆膜上，将切口向胆囊底和胆囊体左侧延伸，如果炎症明显，可先于浆膜下注射少量生理盐水使剥离容易。提起胆囊，用止血钳向两侧及胆囊床分离，遇到出血予以钳夹止血，将胆囊自胆囊床上完整分离下来，注意勿撕裂胆囊床深部的肝组织。 ? 用1号线将胆囊床两侧残余浆膜间断缝合，予以包埋。如果床面有渗血，可以填入几块明胶海绵，再间断缝合包埋。肝十二指肠韧带切口，可以用1号线间断缝几针，以使其腹膜化，减少术后粘连。 ?自胆囊底开始的胆囊切除术:提起胆囊底部浆膜，距肝脏1cm切开浆膜，向两侧延伸直至胆囊颈部。分离胆囊，先行钝性分离两侧浆膜，分离到胆囊床边缘时，提起胆囊底，自上而下将胆囊自胆囊床上分离下来，直至胆囊颈部。 ? for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet 小心、仔细分离出胆囊管，于其内上方分离出胆囊动脉，并靠近胆囊将胆囊动脉切断，用7号线结扎残端，4号线缝扎。 ? 提起胆囊，距胆总管0.3,0.5cm处将胆囊管夹住切断，残端先用7号线结扎，再用4号线缝扎。移走胆囊，用1号线将胆囊床两侧的浆膜间断缝合，以包埋胆囊床。用1号线间断缝合肝十二指肠韧带切口。 4.关腹:用干净纱布将手术野中的渗液吸净，于网膜孔处放一根硅胶管引流，自右肋缘下引出腹腔外，并将其固定于皮肤上。清理腹腔，清点器械、敷料，按常规缝合腹前壁各层。皮肤缝合:?、进针缝合时左手执有齿镊，提起皮肤边缘，右手执持针钳，用腕臂力由外旋进，顺针的弧度剌入皮肤，经皮下从对侧切口皮缘穿出; ?、拔针可用有齿镊顺针前端顺针的弧度外拔，同时持针器从针后部顺势前推;?、出针、夹针当针要完全拔出时，阻力已很小，可松开持针器，单用镊子夹针继续外拔，持针器迅速转位再夹针体(后1,3弧处)，将针完全拔出，由第一助手打结，第二助手剪线，完成缝合步骤。 五、手术中的护理 1.患者进入手术室热情接待 2.核对患者 3.关心安慰患者舒缓其紧张 4.做好保暖护理 5.密切观察患者生命体征 6.做好输液护理 for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet 7.配合好医生进行手术 六、术后护理 1.术后取半坐位，以利于手术区渗液的引流。 2.持续胃肠减压，可以减轻术后腹胀。一般3,5天，胃肠蠕动恢复以后，可以拔除，进流质、半流质直至普通饮食。 3.禁食期间需静脉输液，给予晶体和适量胶体。 4.全身用广谱抗生素，可根据需要联合使用。 5.腹腔引流，观察引流液的质和量，术后3,5天无增加，可以拔除引流管。 6.术后1周拆线。 for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet