Novitsky Yuri W, Kercher Kent W, Czerniach Donald R, Kaban Gordie K, Khera Samira, Gallagher-Dorval Karen A, Callery Mark P, Litwin Demetrius E M, Kelly John J
Department of Surgery, University of Massachusetts Medical School, Worcester, USA.
Arch Surg. 2005 Dec;140(12):1178-83. doi: 10.1001/archsurg.140.12.1178.
The use of smaller instruments during laparoscopic cholecystectomy (LC) has been proposed to reduce postoperative pain and improve cosmesis. However, despite several recent trials, the effects of the use of miniaturized instruments for LC are not well established. We hypothesized that LC using miniports (M-LC) is safe and produces less incisional pain and better cosmetic results than LC performed conventionally (C-LC).
A patient- and observer-blinded, randomized, prospective clinical trial.
A tertiary care, university-based hospital.
Seventy-nine patients scheduled for an elective LC who agreed to participate in this trial were randomized to undergo surgery using 1 of the 2 instrument sets. The criteria for exclusion were American Society of Anesthesiologists class III or IV, age older than 70 years, liver or coagulation disorders, previous major abdominal surgical procedures, and acute cholecystitis or acute choledocholithiasis.
Laparoscopic cholecystectomy performed with either conventional or miniaturized instruments.
Patients' age, sex, operative time, operative blood loss, intraoperative complications, early and late postoperative incisional pain, and cosmetic results.
Thirty-three C-LCs and 34 M-LCs were performed and analyzed. There were 8 conversions (24%) to the standard technique in the M-LC group. No intraoperative or major postoperative complications occurred in either group. The average incisional pain score on the first postoperative day was significantly less in the M-LC group (3.9 vs 4.9; P = .04). No significant differences occurred in the mean scores for pain on postoperative days 3, 7, and 28. However, 90% of patients in the M-LC group and only 74% of patients in the C-LC group had no pain (visual analog scale score of 0) at 28 days postoperatively (P = .05). Cosmetic results were superior in the M-LC group according to both the study nurse's and the patients' assessments (38.9 vs 28.9; P<.001, and 38.8 vs 33.4; P = .001, respectively).
Laparoscopic cholecystectomy can be safely performed using 10-mm umbilical, 5-mm epigastric, 2-mm subcostal, and 2-mm lateral ports. The use of mini-laparoscopic techniques resulted in decreased early postoperative incisional pain, avoided late incisional discomfort, and produced superior cosmetic results. Although improved instrument durability and better optics are needed for widespread use of miniport techniques, this approach can be routinely offered to many properly selected patients undergoing elective LC.
有人提出在腹腔镜胆囊切除术（LC）中使用更小的器械可减轻术后疼痛并改善美观效果。然而，尽管近期有多项试验，但使用小型化器械进行LC的效果仍未明确。我们推测，与传统LC（C-LC）相比，使用微型端口的LC（M-LC）是安全的，且切口疼痛更少，美容效果更好。
一项患者和观察者双盲、随机、前瞻性临床试验。
一家三级护理的大学附属医院。
79例计划接受择期LC且同意参与本试验的患者被随机分为两组，使用其中一套器械进行手术。排除标准为美国麻醉医师协会分级III或IV级、年龄大于70岁、肝脏或凝血功能障碍、既往有重大腹部手术史、急性胆囊炎或急性胆管结石。
使用传统或小型化器械进行腹腔镜胆囊切除术。
患者的年龄、性别、手术时间、术中失血、术中并发症、术后早期和晚期切口疼痛以及美容效果。
共进行并分析了33例C-LC和34例M-LC。M-LC组中有8例（24%）转为标准技术。两组均未发生术中或重大术后并发症。M-LC组术后第1天的平均切口疼痛评分显著低于C-LC组（3.9比4.9；P = 0.04）。术后第3、7和28天的疼痛平均评分无显著差异。然而，M-LC组90%的患者在术后28天无疼痛（视觉模拟评分0分），而C-LC组仅74%的患者如此（P = 0.05）。根据研究护士和患者的评估，M-LC组的美容效果均更优（分别为38.9比28.9；P<0.001，以及38.8比33.4；P = 0.001）。
使用10毫米脐部、5毫米上腹部、2毫米肋下和2毫米侧方端口可安全地进行腹腔镜胆囊切除术。使用微型腹腔镜技术可减轻术后早期切口疼痛，避免晚期切口不适，并产生更优的美容效果。尽管广泛应用微型端口技术需要提高器械耐用性和光学性能，但这种方法可常规应用于许多经适当选择的择期LC患者。
