电视胸腔镜在穿透性胸腹联合伤中的应用

Role of Video-assisted Thoracic Surgery in management of Penetrating Thoracoabdominal Injuries

目的探讨电视胸腔镜诊治穿透性胸腹联合伤的价值。方法全麻,双腔气管插管,胸腔镜探查损伤情况。损伤轻微者可行胸腔镜辅助胸壁小切口治疗。胸壁、胸膜腔出血行电凝止血、缝合止血、凝血块清除,多数膈肌裂伤可同时修补,出血、裂伤脏器可行修补或切除治疗。损伤严重者中转开胸、开腹探查。结果全组18例,电视胸腔镜辅助胸壁小切口完成胸部手术15例(膈肌修补15例,肋间动脉止血8例,肺修补2例,肺楔形切除2例,凝固性血胸清除2例),中转开胸3例(膈肌修补3例,心脏修补1例,食管修补1例,肺叶切除2例)。经胸行腹腔诊治13例(肝脏修补1例,脾脏切除1例,胃修补1例,膈疝还纳3例,探查7例),开腹诊治5例(胰腺修补1例,肝脏修补1例,脾脏切除1例,胃修补2例,大网膜及肠系膜修补3例)。1例多脏器穿透伤患者,虽经开胸、开腹治疗,但终因失血性休克、循环衰竭、DIC死亡。手术时间45～220min,(125±44)min;术中出血量500～10000ml,(1089±582)ml;术后24h胸腔引流量100～350ml,(234±75)ml;术后胸管留置时间2～5d,平均2.5d;术后排气时间1～4d,平均2d。12例门诊随访3～12个月,平均6个月,无与外伤相关的并发症发生。结论恰当地选择病例,电视胸腔镜辅助胸壁小切口诊治穿透性胸腹联合伤安全,疗效可靠。

Objective To evaluate the value of video-assisted thoracic surgery （VATS） for penetrating thoracoabdominal injuries. Methods Under general anaesthesia and double-lumen tracheal intubation, VATS was carried out to examine patients with chest injuries. Those who had mild injuries received VATS combined with mini-incision surgery. Electrocoagulation or suturing was employed to control intraoperative bleeding, and then blood clots were removed. Injured diaphragm muscles were repaired, and organs with hemorrhage or ruptures were sutured or resected. The seriously injured cases underwent open surgery and intra-abdominal exploration instead. Results A total of 18 patients received the operations. Among them, 15 patients underwent VATS combined with mini-incision surgery （repair of the diaphragm was performed on 15, controlling intercostal arterial bleeding on 8, repair of the lung on 2, wedge resection of the lung on 2, and coagulated hemothorax removal on 2） , the other 3 were converted to open surgery for repairing the diaphragm （3） , heart （ 1 ） , or esophagus （ 1 ） , or lobectomy （2）. Abdominal surgery via the thorax were performed on 13 cases, including repair of the liver in 1, lienectomy in 1 , gastrorrhaphy in 1, repair of diaphragmatic hernia in 3, and intraabdominal exploration in 7. Five patients received open surgery （pancreatic neoplasty in 1 , repair of the liver in 1, lienectomy in 1, gastrorrhaphy in 2, and repair of the caul and mesenterium in 3 ）. One patient who had multi-organ penetrating injuries died of hemorrhagic shock, circulatory failure, and DIC after open thoracic and abdominal surgeries. The mean operation time in this series was （125 _＋44） minutes （ranged from 45 to 220） , and the mean blood loss was （1089 ±582） ml （500 to 10 000 ml）. Twenty-four hours after the operation, the mean volume of chest drainage was （234 ± 75） ml （100 to 350 ml） in the first 24 hours after the operation. The chest drainage tube was withdrawn 2.5 （2 to 5 ） days postoperation. The patients expelled gas in 1 to 4 days （ mean, 2 days）. Totally, 12 patients were followed up for 3 to 12 months （mean, 6 months） , during which none of them had trauma-related complications. Conclusion VATS combined with mini-incision surgery is safe and effective for patients with thoracoabdominal injuries, if the cases were carefully selected.