腹腔镜辅助下经肛门逐层梯度切除直肠肌鞘治疗先天性巨结肠  

Modified laparoscopic-assisted soave pull-through procedure with stepwise and gradient muscular cuff cut- ting for Hirschsprung＇s disease

作　　者：刘远梅[1] 金祝[1] 郑泽兵[1] 王鑫[1] 高明娟[1] 曲颜[1] 

机构地区：[1]遵义医学院附属医院小儿普胸泌外科,563003

出　　处：《中华小儿外科杂志》2013年第11期823-825,共3页Chinese Journal of Pediatric Surgery

基　　金：贵州省省长基金l临床应用专项基金[黔省专合字（2012）98号]

摘　　要：目的探讨腹腔镜辅助经肛门逐层梯度切除直肠肌鞘治疗先天性巨结肠（HD）的可行性及有效性。方法回顾性分析2009年12月至2013年3月腹腔镜辅助经肛门逐层梯度切除直肠肌鞘改良Soave治疗先天性巨结肠44例患儿的临床资料，男37例，女7例，年龄25d至5岁，平均1．8岁，术前根据临床表现、钡剂灌肠、直肠肛管测压、直肠黏膜及肌层活检诊断，普通型27例，长段型17例，手术方法在原Soave的基础上改进，齿线上约0．5～1cm针形电刀环形切开直肠黏膜，逐层梯度电凝分离切除直肠环肌、纵肌，达腹膜返折，术后随访Kell评分评价肛门功能。结果腹腔镜辅助改良Soave根治手术43例，中转开腹1例，切除降结肠以远肠管39例，结肠次全切除5例，术中出血量15-25ml，手术时间90-220min，平均150min，无术中并发症，术后排便时间8～24h，平均16h，术后住院时间6～14d，平均8d，术后发生结肠不全梗阻1例，肛周皮炎8例，住院期间无吻合口瘘及小肠结肠炎发生；44例均获随访，随访时间2～36个月，平均随访时间14个月，发生小肠结肠炎1例，污粪7例，肛门狭窄1例，无便秘复发，Kell评分肛门功能优良率95．40／／oo。结论腹腔镜辅助经肛门逐层梯度切除直肠肌鞘改良Soave治疗巨结肠安全、有效，术后可获得较好排便功能。Objective To evaluate the safety and feasibility of laparoscopic-assisted endorectal pull-through （LAEPT） for Hirschsprung＇s disease （HD） with stepwise and gradient muscular cuff cutting modification. Methods We retrospectively analyzed 44 patients （37 males and 7 females, aged between 25 days to 5 years old, mean age of 1.8 years old） with HD who underwent modified LAEPT from December 2009 to March 2013. All patients were diagnosed with HD preoperatively by clinical presentation, barium enema, anorectal manometry, and rectal biopsy. Short segment accounted for 27 cases while there were 17 cases of long segment. The LAEPT approach was modified by dissecting the mucosa circumferentially 0. 5-1 cm above the dentate line, followed by dissecting circular and longitudi- nal muscles in a stepwise method upwards to the peritoneal reflection. Anorectal function was evalua- ted with Kelly score. Results Forty-three patients were successfully operated on using modified LAE- PT, the other 1 patient needed to be converted. Resection of descending colon was done in 39 cases; subtotal colectomy in 5 cases. The mean operative time was 150 mins. The mean defecation time after surgery was 16 hrs （range 8-24 hrs）. The mean postoperative hospital stay was 8 days （range 6-14 d）. In 8 cases, perioperative perianal excoriation occurred. There was no anastomotic leakage or en- terocolitis. During follow-up ranging from 2-36 months, 1 case of enterocolitis, 7 cases of soiling, 1 case of anal stenosis were seen. Excellent and good bowel function was achieved in 95.4% patients. Conclusions Modified laparoscopic-assisted soave pull-through procedure with stepwise muscular cuff cutting is safe and effective, with good post-operative defecative function.

关 键 词：HIRSCHSPRUNG病 外科手术 腹腔镜 

分 类 号：R726.5[医药卫生—儿科]