完全腹腔镜巨脾联合贲门周围血管离断术治疗门静脉高压症

Laparoscopic splenectomy and pericardial devascularization for treatment of portal hypertension due to liver cirrhosis

目的总结完全腹腔镜下巨脾切除联合贲门周围血管离断术治疗肝硬化门静脉高压症的手术技巧和临床应用价值。方法回顾性总结了2005年3月—2006年9月间,一个治疗小组对23例肝硬化门静脉高压致食管下端静脉曲张患者应用超声刀行完全腹腔镜下巨脾切除联合贲门周围血管离断术治疗的临床资料。结果 23例中有20例在处理脾蒂前结扎脾动脉;中转开腹3例(13.0%),其中脾叶静脉破裂出血2例,左膈静脉破裂出血1例;20例顺利完成手术,其中18例应用二级脾蒂离断法处理脾蒂-逐支分离脾叶动静脉,边分离边用血管夹夹闭或丝线结扎离断血管,2例应用腔内直线型切割钉合器(Endo-GIA)集束离断二级脾蒂血管。手术时间180～350 min,平均235min。术中失血200～1600 ml,平均520 ml。术后经输血浆、利尿、预防抗炎治疗。术后发生胸腔积液3例,左膈下脓肿1例,B 超引导穿刺治愈,轻度腹水2例。无死亡病例。术后住院时间6～17 d,平均8.5 d。术后平均随访时间9个月,再出血率0%。结论娴熟的互相配合的腹腔镜技术、术中应用超声刀和预先结扎脾动脉,应用二级脾蒂离断法处理脾蒂是完全腹腔镜下巨脾切除联合贲门周围血管离断术手术成功的关键技术要素。手术仍具有微创的优势。

Objective To evaluate the safety and efficacy of laparoscopic splenectomy （LS） and pericardial devascularization in treatment of portal hypertension due to liver cirrhosis. Methods Twenty three cases with hepatitis B and schistosoma cirrhosis and portal hypertension underwent LS and paraesophagogastric devascularization performed by one treatment team. Follow-up was conducted for 9 months. Results LS combined with pericardial devascularization was successfully performed on these 20 cases. Three cases were converted to open surgery due to intra-operative bleeding. The mean operative time was 235 min （180 -350）, and mean intra-operative blood loss was 520 ml （200 - 1600 ml）. All patients were treated with plasma transfusion, antibiotics, and abdominal drainage post-operatively. Peristalsis of stomach and intestine recovered 24 -72 hours after operation. The mean hospitalization time was 8.5 days （ 6 - 17 days）. The peri-operative complication included plural effusion in 3 cases and subphrenic abscess in one case, . mild ascites in two cases, and wound dehiscence in one case. No mortality occurred. Rebleeding rare was 0%. Conclusion LS combined with pericardial devascularization is relatively safe and effective in treatment of portal hypertension due to liver cirrhosis. The keys to success include experienced laparoscopic skills, use of harmonic scalpel and careful manipulation.