血友病合并胆石症行腹腔镜手术的围手术期处理体会

Perioperative experience of laparoscopic surgery in patients with hemophilia and cholelithiasis

目的 初步探讨运用腹腔镜技术对血友病患者实施手术的安全性和有效性.方法 回顾分析2009年2月至12月收治的5例血友病患者,在应用血浆FⅧ：C/FⅨ：C制剂情况下行腹腔镜手术的围手术期情况.观察手术用时、术中出血量、术后通气和进食时间、术后并发症等,监测凝血功能（FⅧ：C/FⅨ：C、APTT）、黄疸程度、肝功能的变化.结果 手术用时60～120min,平均80min.出血量平均约100ml,均无中转开腹,术后1～2d通气、2～3d进食,均无腹腔出血、感染、肠梗阻等并发症.2例肝功能损害和黄疸病例在术后肝功能各项指标逐渐恢复正常,黄疸逐渐消褪.5例术后7～12d出院,平均9d.4例血友病甲患者手术前后1d FⅧ：C维持在100%左右,继续使用替代制剂后维持在60%左右.1例血友病乙患者手术前后1d FⅨ：C维持在50%左右.5例患者APTT术前64.7～145.1s,平均91.2s,运用替代制剂后大幅缩短,其中4例保持在正常范围左右.结论 对于血友病患者,经过周密的围手术期准备,维持FⅧ：C/FⅨ：C在理想水平,实施腹腔镜手术是安全有效的.

Objective To explore the safety and effectiveness of laparoscopic surgery in patients with hemophilia. Methods The clinical data from February to December in 2009 of 5 patients with hemophilia who were undergone by laparoscopic surgery in the condition of using plasma FⅧ ： C/FⅨ ： C was reviewed. Time of operation, amount of bleeding, postoperative evacuation and the feeding point, postoperative complications were observed. Blood FⅧ ： C/FⅨ ：C, APTT, degree of jaundice and liver function were evaluated. Results The time of the operation was 60 - 120 minutes with average time 80 minutes ,and the average amount of bleeding was about 100 ml. There was no transition to open operation. After the operation, the patient evacuated in the next one or two days, began to eat on the second or third day. There were no severe operative complications such as intra - abdominal infections, intestinal obstruction, etc. The jaundice of two patients with bad liver function vanished after the operation. 5 patients were discharged from hospital in 7 - 12 days and the average is 9 days. The plasma FⅧ ： C level of 4 patients with hemophilia A remained at about 100% during perioperative days, and remained about 60% after continuing using replacement therapy. The plasma FⅨ ： C level of 1 patient with hemophilia B remains about 50% during perioperative days. APTT of 5 patients was 64.7 - 145.1 s with average 91.2 s and reduced to normal after using replacement therapy before the operation. Conclusion With careful preparation during the perioperative period and keeping the FVⅧ ： C/FⅨ ： C in normal level for the patients with hemophilia A/B,laparoscopic surgery may be safe and effective.