泌尿外科腹腔镜术后并发高碳酸血症的原因分析

Analysis of the causes of hypercarbia following urologic laparoscopy

目的探讨泌尿外科腹腔镜手术后并发高碳酸血症的原因及防治策略.方法回顾性研究腹腔镜手术治疗泌尿外科疾病168例,其中经血气分析诊断并发高碳酸血症9例.从年龄、体重指数、美国麻醉医师协会评分标准(ASA)分级、手术类型、手术入路、腹腔镜手术气腹时间、气腹压、出血量、有无中转等方面评价.结果9例患者手术经后腹腔入路8例、经腹腔1例.>58岁7例,<50岁2例.体重指数>10%～25%8例,标准体重指数1例.ASA分级Ⅰ级2例,Ⅱ～Ⅲ级7例(合并糖尿病、心功能不全4例,合并慢性支气管炎2例,合并轻度肝功能损害1例).手术气腹时间>180 min 6例,110、180 min、<100 min各1例.气腹压力>15 mm Hg 7例,<15 mm Hg2例.手术类型,肾切除1例,肾输尿管全长切除术1例,肾上腺或肾上腺腺瘤切除6例(嗜铬细胞瘤3例,增生1例,腺瘤1例,库兴综合征1例)、乳糜尿1例.出血量>500 ml 5例、300～500 ml 2例、50、200 ml各1例.手术中转3例.结论过于肥胖,高龄,有心血管疾病、糖尿病、呼吸系统疾病或肝功能损害等合并症,经后腹腔入路,手术气腹时间>180 min,气腹压力>15 mm Hg,出血量>300ml等因素与术后并发高碳酸血症有关,是否中转与并发高碳酸血症可能无关.

Objective To investigate the causes of hypercarbia after urologic laparoscopic surgery and the preventive and therapeutic strategy. Methods A total of 168 cases of urinary diseases who underwent laparoscopic surgery were retrospectively analyzed. Of them 9 cases developed hypercarbia following laparoscopy. The evaluations of the related factors were performed, including ： the patients＇ age, body mass index （BMI） ,rank of ASA score, operative pneumoretroperitoneum time and pressure, types of operation, operative approaches （through retroperitoneal or transperitoneal） ,volume of blood loss and conversion to open surgery or not. Results Among the 9 cases of postoperative hypercarbia,8 cases had the operation through retroperitoneal and 1 case through peritoneal approaches. Seven cases were older than 58 years and 2 cases younger than 50 years. Eight cases had BMI 〉 10% -25% and 1 case,normal BMI. Two cases without comorbidity were rated as ASA Rank Ⅰ and 7 cases as ASA Rank Ⅱ - Ⅲ （4 cases with diabetes mellitus or heart failure,2 cases with chronic bronchitis, 1 case with chronic mild hepatic dysfunction）. The operative pneumoretroperitoneum time was 〉 180 min in 6 cases;180 min, 110 min,and 〈 100 min each in 1 case. The operative pneumoretroperitoneum pressure was 〉 15 mm Hg in 7 cases,and 〈 15 mm Hg in 2 cases. Nephrectomy was performed in 1 case,whole ureteronephrectomy in 1 case,adrenal gland resection or adenoma resection in 6 cases （ including 3 cases of pheochromocytoma, 1 of hyperplasia, 1 of adenoma, 1 of Cushing＇ s syndrome） , and operation for chylous urine in 1 case. The volume of blood loss was 〉 500 ml in 5 cases,300 ～ 500 ml in 2 eases,50 ml and 200 ml in 1 case each. Three cases underwent conversion to open surgery. Conclusions Hypercarbia following urologic laparoscopy may be associated with obesity,advanced age,comorbidities （such as cardiovascular diseases, diabetes, respiratory diseases, and chronic hepatic dysfunction） ,retroperitoneal approaches, operative pneumoretroperitoneum time （ 〉 180 min） and pressure （ 〉 15 mm Hg） ,and blood loss 〉300 ml. Whether laparoscopy is converted to open surgery or not seems not a risk factor of hypercarbia. In addition, improvement of the operative skill and shortening of operative time can reduce such complications as hypercarbia.