减少腹腔镜脾切除术术中出血的初步体会

Reduction of Intraoperative Bleeding During Laparoscopic Splenectomy

目的探讨预防和减少腹腔镜脾切除术(laparoscopic splenectomy,LS)术中出血的手术技巧和措施。方法2008年1月～2010年3月行LS 40例。脾动脉位于胰尾上缘者,先分离并结扎脾动脉主干,离断脾周韧带;脾动脉位于胰尾后方或胰尾内者,先离断脾周围韧带和剥离胰尾,显露和离断脾蒂血管,完成LS。结果完成LS 31例,LS联合LC 7例,LS联合胆囊切除,贲门周围血管离断术2例。术中切除副脾3例。手术时间90～210 min,平均130 min;出血量50～800 ml,平均160 ml。术后12～24 h胃肠蠕动恢复,术后24 h拔胃管后进食。术后住院5～9 d,平均7.5 d。1例特发性血小板减少性紫瘢(idiopathic thrombocytopenic purpura,ITP)术后效果不佳,血小板一直<50×109/L,口服泼尼松20 mg/d维持治疗;23例ITP随访4个月～2年,平均1年,无复发;2例门脉高压症随访1年,未发生消化道出血。结论围手术期改善凝血,提高血小板计数,术前行脾动脉CT血管造影,手术时在胰腺上缘结扎脾动脉,分离脾周围韧带时避免撕裂脾包膜,妥善处理脾蒂血管,谨慎对待门脉高压症患者,可减少LS术中出血。

Objective To explore surgical techniques to prevent or reduce intraoperative bleeding during laparoscopic splenectomy（LS）. Methods From January 2008 to March 2010,we performed LS on totally 40 patients.Under general anesthesia,we isolated and ligated the splenic artery,and then cut the peri-splenic ligaments when the splenic artery located above the pancreatic tail,or cut the peri-splenic ligaments and peeled off the pancreas tail first when the splenic artery located in the pancreas or behind the pancreas tail.Afterwards,the vessels of the splenic hilum were exposed and cut,and then the LS was completed.ResultsWith the procedure,we completed LS in 31 patients,LS combined with LC in 7,and LS combined with cholecystectomy plus pericardial devascularization in 2.In addition,accessory splenectomy was performed in 3 of the patients.The operation time ranged from 90 to 210 minutes with a mean of 130 minutes;and intraoperative blood loss ranged from 50 to 800 ml with a mean of 160 ml.Intestinal peristalsis recovered in 12-24 hours after the operation,and gastric tube was withdrawn in 24 hours postoperation.The mean postoperative hospital stay ranged from 5 to 9 days with a mean of 7.5 days.Follow-up was achieved in 23 patients with idiopathic thrombocytopenic purpura（ITP） for 4 months to 2 years（mean,1 year）,during which no patients had recurrence.Surgical outcomes were not good in one case of ITP,whose level of platelet had been sustained at 50×109/L,and therefore had been taken metacortandracin orally at a dose of 20 mg/d.Two patients,who had had portal hypertension,were followed up for one year,during which no gastrointestinal hemorrhage occurred. Conclusion To reduce intraoperative bleeding during LS,we recommend improving blood coagulation and enhancing platelet count perioperatively,carrying out splenic artery CTA preoperatively,and ligating the splenic artery above the pancreatic tail intraoperatively to avoid tearing the spleen capsule when dissecting the peri-splenic ligaments,as well as handling the vessels of the splenic hilum properly,and being cautious to the patients with portal hypertension.