腹腔镜门静脉高压症贲门周围血管离断术的风险评估和手术技巧  

Surgical technique and risk assessment of laparoscopic splenectomy and esophagogastric devascularization for portal hypertension

作　　者：曹庭加[1] 胡逸林[1] 李汉军[1] 汪波[1] 张扬[1] 卢绮萍[1] 

机构地区：[1]广州军区武汉总医院普通外科,武汉430070

出　　处：《中华腔镜外科杂志（电子版）》2013年第6期37-40,共4页Chinese Journal of Laparoscopic Surgery(Electronic Edition)

摘　　要：目的探讨腹腔镜在外科治疗门静脉高压症手术风险及手术技巧。方法自2011年6月以来,46例诊断为肝炎肝硬变、门静脉高压症、食管胃底静脉曲张,肝功能分级Child A级32例,B级14例。术前胃镜检查了解食管胃底静脉曲张;门静脉彩超,了解门静脉有无血栓;上腹部CT增强扫描,了解脾脏大小,脾动、静脉走行,二级脾蒂分叉部位,脾门以及胃底、贲门周围曲张静脉分布情况。采用4孔法,取脐上10 mm戳孔为腹腔镜观察孔,左锁骨中线约与脐平线12 mm戳孔,为主操作孔;剑突左侧肋缘下2 cm处5 mm戳孔、左腋前线约与脐平线12 mm戳孔为辅操作孔,术者、一助均位于患者右侧。LS技术操作我们采用前入路与侧入路结合方法,离断脾动脉、胃短血管时用前入路,游离脾肾、脾膈韧带,离断脾蒂时运用侧入路;贲门周围血管离断采用前入路。结果全腹腔镜成功实施38例肝硬化门静脉高压症脾切除加贲门周围血管离断术,7例术中出现不可控出血中转,1例慢性胰腺炎术中无法分离出脾动脉中转。手术时间142～218 min,平均(167±44)min,术中出血80～280 ml,平均(113±76)ml。采用预先结扎脾动脉,Endo Cut闭合切割一级脾蒂或二级脾蒂,无出血、胰漏并发症,无死亡病例。术后第2天拔除胃管,第3天拔除腹腔引流管,术后7～12 d出院。结论通过上腹部CT,谨慎进行贲门周围血管离断术手术风险评估,正确的操作步骤,准确的分离层面,娴熟的腹腔镜下分离技巧,处理脾蒂血管动作精细,预防出血,保持视野清晰,尽管风险很大,腹腔镜手术治疗门静脉高压症还是安全、可行的。Objective To study the surgical technique and risk assessment of laparoscopic splenectomy and esophagogastric devascularization for portal hypertension. Methods The clinical data of 46 cases with portal hypertension undergoing laparoscopic splenectomy and esophagogastric devascularization from June 2011 to Jan. 2013 were retrospectively analyzed. Results Laparoscopic splenectomy and esophagogastric devascularization were successfully performed on 38 cases, and 8 cases were converted to open surgery （with 17.4% conversion rate）. There were no operative complications and deaths. Conclusion The patients with portal hypertension undergoing laparoscopic splenectomy and esophagogastric devascularization should be assessed preoperatively according to the imaging. The laparoscopic surgical indications must be strictly held. And treatment of splenic pedicle was the key to the success of laparoscopic surgery. Intraoperative bleeding was the main reason of conversion of laparoscopic surgery to open surgery. Intraoperative cautious and decisive judgment on the transit operation time were the most important to ensure the safety of patients. In spite of high risk, laparoscopic splenectomy and esophagogastric devascularization for patients with portal hypertension was safe and feasible if key techniques well mastered.

关 键 词：门静脉高压 腹腔镜检查 脾切除术 危险性评估 贲门周围血管离断 

分 类 号：R657.3[医药卫生—外科学]