臺灣博碩士論文加值系統

膽囊切除，亦即以外科手術摘除生病的膽囊，是最常被施行的手術之一。從１９９０年代起，腹腔鏡膽囊切除（ＬＣ）成為治療良性膽囊疾病的標準術式，而開腹式膽囊切除成為在困難腹腔鏡手術中當病人的安全有疑慮時的轉換術式或針對因身體狀況不佳而無法接受腹腔鏡手術的病患的最後一線手術。總膽管探查術是治療膽管結石除了逆行性膽胰攝影（ＥＲＣＰ）及內視鏡壺腹擴約肌切開（ＥＳ）以外另一個廣被接受的治療選擇。然而，在腹腔鏡的時代來臨後，腹腔鏡總膽管探查術（ＬＣＢＤＥ）的採用卻受限於該術式的複雜技巧。近二十年來，單一切口腹腔鏡手術（或腹腔內視鏡單處手術）已被應用在各個領域以減少手術切口對病患造成的傷害。
在２０１０年３月，我們從三切口腹腔鏡膽囊切除手術（３ＩＬＣ）及二切口腹腔鏡膽囊切除手術（２ＩＬＣ）逐步的演進下，發展出了以傳統直式器械進行單一切口腹腔鏡膽囊切除手術（SＩＬＣ）。在一篇包含了我們前三十三例ＳＩＬＣ，十例２ＩＬＣ及二十四例３ＩＬＣ的回溯性研究中，顯示ＳＩＬＣ與傳統多切口ＬＣ針對治療非複雜良性膽囊疾病的選擇性病患同樣是可實施且安全的。較輕微的術後疼痛及較佳的傷口美觀是其潛在的優勢，但缺點是需要較長的手術時間。
從２０１０年５月起，我們開始採用ＳＩＬＣ作為治療急性膽囊炎的一個選擇術式。一篇比較六十二例ＳＩＬＣ及四十六例３ＩＬＣ治療急性膽囊炎的回溯性研究顯示，ＳＩＬＣ和傳統多切口ＬＣ針對治療複雜性膽囊疾病的選擇性病患同對是安全且有效的；但為了確保病人安全，手術轉換的門檻需要降低。以ＳＩＬＣ治療急性膽囊炎的合併症極低，而主要好處是病患術後恢復較快。
在施行了７３例ＳＩＬＣ（５２例單純膽囊疾病及２１例複雜病例）而只發生３例（４.１％）Clavien-Dindo 分類第一級的合併症後，我們在２０１２年３月把這個術式提供給所有良性膽囊疾病的病患作為常規術式。我們一篇包含了兩百例連續ＳＩＬＣ的觀察性研究顯示，以常規SＩＬＣ來治療良性膽囊疾病在成熟期是安全可行的。根據學習曲線的分析，施行ＳＩＬＣ來治療單純膽囊疾病有助於此技術在複雜疾病上的成熟。男性病患和複雜膽囊疾病與較高手術轉換率有關，而年長病患較易發生合併症。
我們於２０１２年7月研發的創新單一切口腹腔鏡總膽管探查術（ＳＩＬＣＢＤＥ），如今已成為我們在臨床上清除膽管結石的標準術式。一篇初步的回溯性研究顯示ＳＩＬＣＢＤＥ和傳統多切口ＬＣＢＤＥ相比同樣是安全且有效的。除了廣為人知的傷口美觀以外，這個新穎手術的其他優點尚需後續的研究來證實。

Cholecystectomy, surgical removal of the diseased gallbladder, is one of the most common surgical procedures. While laparoscopic cholecystectomy (LC) becomes the standard procedure to treat benign gallbladder disease since 1990s, open cholecystectomy (OC) serves as a converted procedure in case patient safety is doubtful in difficult laparoscopic operations or a salvage procedure for patients who can’t tolerate a laparoscopic operation owing to poor general conditions. Common bile duct exploration is a well-established treatment option for choledocholithiasis alternative to retrograde endoscopic cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES). In the laparoscopic era, however, the adoption of laparoscopic common bile duct exploration (LCBDE) is limited due to the technical complexity. Single-incision laparoscopic surgery (SILS) which is also known as laparoendoscopic single-site (LESS) surgery has been applied in various fields to minimize the traumatic effects in recent two decades.
We developed single-incision laparoscopic cholecystectomy (SILC) with conventional straight instruments as a step-by-step evolution of three-incision laparoscopic cholecystectomy (3ILC) and two-incision laparoscopic cholecystectomy (2ILC) in March 2010. A retrospective comparative study including our first 33 SILCs, 10 2ILCs, and 24 3ILCs showed SILC is feasible and safe for selective patients with uncomplicated benign gallbladder diseases compared to conventional multi-incision LC. Less postoperative pain and better cosmesis are the potential benefits but longer operative time is the drawback.
Since May 2010, we began to adopt SILC as an optional procedure for acute cholecystitis. Our retrospective study comparing 62 SILCs and 46 3ILCs for acute cholecystitis revealed SILC is as safe and efficacious as traditional multi-incision LC for selective patients with complicated gallbladder diseases providing a low threshold for procedure conversion can be maintained. The complication rate is low and the major benefit for patients is faster recovery.
After 73 SILCs (52 for uncomplicated diseases and 21 for complicated ones) were accomplished with three (4.1%) Clavien-Dindo classification grade I complications, we offered this technique to all the patients with benign gallbladder diseases as a routine procedure in March 2012. Our observational study comprising 200 consecutive SILCs revealed routine SILC for benign gallbladder diseases is safe and feasible in the experienced phase. According to the learning curve analysis, practicing SILC for uncomplicated gallbladder diseases helps to achieve competence in this technique for complicated diseases. Male gender and complicated gallbladder diseases were associated with a higher procedure conversion rate and aged patients were more liable to complications.
Single-incision laparoscopic common bile duct exploration (SILCBDE), an innovative technique we developed in July 2012, has become the standard procedure for bile duct stone clearance by our clinical practice. A preliminary retrospective comparative study showed SILCBDE is safe and effective compared to conventional multi-incision laparoscopic common bile duct exploration (LCBDE). The potential benefits of this novel technique other than the well-known cosmetic advantage need further investigations.

Acknowledgements...i
Abstract in Chinese...iii
Abstract in English...v
Abbreviation...viii
Contents...x
List of Tables...xiii
List of Figures...xv
1. Introduction...1
1.1. Laparoscopic cholecystectomy...1
1.2. Single-incision laparoscopic surgery...2
1.3. Single-incision laparoscopic cholecystectomy...4
1.4. Single-incision laparoscopic cholecystectomy for acute cholecystitis...6
1.5. Routine single-incision laparoscopic cholecystectomy...7
1.6. Laparoscopic common bile duct exploration...7
2. Research Approaches...10
3. Materials and Methods...11
3.1. Surgical technique of single-incision, two-incision, and three-incision laparoscopic cholecystectomies...11
3.2. Modified surgical technique of single-incision laparoscopic cholecystectomy for difficult gallbladders (acute cholecystitis)...12
3.3. Surgical technique of single-incision and standard multi-incision laparoscopic common bile duct explorations...13
3.4. Design of the comparative study of single-incision versus two-incision versus three-incision laparoscopic cholecystectomy for uncomplicated gallbladder diseases...16
3.5. Design of the comparative study of single-incision versus three-incision laparoscopic cholecystectomy for acute cholecystitis...17
3.6. Design of the observational study of selective and routine single-incision laparoscopic cholecystectomy for all benign gallbladder diseases...18
3.7. Design of the comparative study of single-incision versus standard multi-incision laparoscopic common bile duct exploration...19
4. Results...22
4.1. Comparison of single-incision versus two-incision versus three-incision laparoscopic cholecystectomy for uncomplicated gallbladder diseases...22
4.2. Comparison of single-incision versus three-incision laparoscopic cholecystectomy for acute cholecystitis...22
4.3. The observational study of selective and routine single-incision laparoscopic cholecystectomy for all benign gallbladder diseases...24
4.3.1. Comparison of selective versus routine single-incision laparoscopic cholecystectomy for all benign gallbladder diseases...24
4.3.2. The learning curve fitting in single-incision laparoscopic cholecystectomy for uncomplicated and complicated gallbladder diseases...25
4.3.3. The analyses of procedure conversion and perioperative complications in single-incision laparoscopic cholecystectomy for all benign GB diseases...26
4.4. Comparison of single-incision versus standard multi-incision laparoscopic common bile duct exploration...27
5. Discussion...30
5.1. Single-incision versus two-incision versus three-incision laparoscopic cholecystectomy for uncomplicated gallbladder diseases...30
5.2. Single-incision versus three-incision laparoscopic cholecystectomy for acute cholecystitis...32
5.3. The observational study of selective and routine single-incision laparoscopic cholecystectomy for all benign gallbladder diseases...36
5.3.1. Selective versus routine single-incision laparoscopic cholecystectomy for all benign gallbladder diseases...36
5.3.2. The learning curves in single-incision laparoscopic cholecystectomy for uncomplicated and complicated gallbladder diseases...37
5.3.3. Procedure conversion and perioperative complications in single-incision laparoscopic cholecystectomy for all benign GB diseases...38
5.4. Single-incision versus standard multi-incision laparoscopic common bile duct exploration...40
5.5. Single-incision laparoscopic common bile duct exploration via choledochotomy or transcystic approach: an ongoing study...44
5.6. Prospective randomized controlled trials...45
5.7. Establishment of the training programs of single-incision laparoscopic cholecystectomy and common bile duct exploration...48
5.8. Single-incision laparoscopic cholecystectomy by robotic surgery: robotic single-site cholecystectomy...48
5.9. Practicing single-incision laparoscopic cholecystectomy in rare scenarios...49
5.10. Application of single-incision laparoscopic surgery to other alimentary tract diseases...49
6. Conclusions...51
7. References...53
Table...64
Figure...81
8. Appendix...93

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