完全腹膜外疝修补(TEP)手术腹膜前CO_2充气对人体的影响

Effect of preperitoneal CO_2 insufflation on human body during laparoscopic totally extraperitoneal hernia repair

目的完全腹膜外疝修补(TEP)手术需在腹膜前建立间隙,并且应用CO2充气维持足够的操作空间。本临床研究通过腹膜前CO2充气对患者呼吸和循环的影响,从病理生理学的角度来论证TEP手术的安全性。方法2005年1月至6月,本中心行TEP手术的腹股沟疝患者20例(18例斜疝,2例直疝),均为男性,年龄平均60.2岁。腹膜前建立间隙并用CO2充气,维持压力于12mmHg,分别记录充气前、充气后5min、充气后30min、拔管后四个时间段的心率(HR)、血压(BP)、呼气末CO2分压(EtCO2)以及血气分析测定值(PH、PCO2、HCO3)。结果进行统计分析。结果手术均顺利完成,手术时间平均32.6min,术后疼痛分数(VAS)平均(2.7±1.4)分,术后住院平均(3.2±0.5)d,3例患者出现皮下气肿。病理生理指标中HR和PH值在充气后有一定幅度的下降,BP、EtCO2、PCO2和HCO3值在充气后有一定幅度的上升,与充气前指标差异有统计学意义,并且随着充气时间延长变化幅度有所增加,各指标在拔管后迅速恢复并接近充气前水平。结论TEP手术腹膜前CO2充气,CO2在皮下组织弥散可能会形成皮下气肿,CO2吸收会出现CO2蓄积及酸中毒,并造成血压上升及心率减慢。通过麻醉师的合理处理,可以将指标控制在合理的安全范围内,术后能迅速恢复。

Objective Preperitoneal CO2 insufflation is required for installation of operative field during laparoscopic totally extraperitoneal hernia repairs （TEP）. This study aimed to investigate the hemodynamic and respiratory effect of preperitoneal CO2 insufflation and evaluate the safety of TEP. Methods From January 2005 to June 2005, 20 consecutive patients （mean age ： 60.2）underwent TEP in our centre were admitted for this study. Preperitoneal CO2 insufflation was performed and maintained at 12 mm Hg during procedures. Heart rate, blood pressure, end-tidal CO2 （ EtCO2 ） and blood gas were measured at the following time points ： before insufflation, 5 rain after insufflation, 30 min after insufflation and after extubation. Results All operations were performed uneventfully. The mean operative time was 32.6min. The mean visual analogue score of postoperative pain was （2.7 ± 1.4） and the mean hospital stay was （3.2 ± 0.5 ） days. Three patients complicated with cutaneous emphysema. MAP , PCO2, HCO3 , EtCO2 increased with HR , PH decreased after insufflation and significant was observed. All hemodynamic and respiratory parameters returned to the preoperative level after extubation. Conclusions Preperitoneal CO2 insufflations in laparoscopic totally extraperitoneal hernia re- pairs may increase the subcutaneous diffuse and absorption of CO2, which facilitates the CO2 accumulation and results in acidosis. Appropriate managements of the hemodynamics and respiratory variations during operation can control the patient＇ s cardiopulmonary function well and the TEP is safe.