非气腹腹腔镜用于老年妇科手术对呼吸循环应激及并发症的影响

Effects of gasless laparoscopy on circulation, respiration, stress response and complications in gynecologic surgery in elderly patients

目的探讨非气腹腹腔镜应用于老年妇科手术对呼吸和循环功能、应激反应及并发症的影响。方法选择行腹腔镜妇科手术的老年患者40例,美国麻醉医师学会分级Ⅱ～Ⅲ级,年龄60～70岁,随机分为非气腹组和气腹组,每组20例。全身麻醉维持期设定潮气量为8mL/kg,呼吸频率12次/min,吸呼比1∶2,吸入氧浓度为100%。分别在麻醉后(T1)、悬吊/气腹后10min(T2)、悬吊/气腹后30min(T3)、解除悬吊/气腹后10min(T4)4个时间点,记录平均动脉压(MAP)、中心静脉压(CVP)、心率、脉搏血氧饱和度(SpO2)、胸肺顺应性、气道峰压、气道平台压、血气分析、血皮质醇、白细胞介素(IL)-6、肿瘤坏死因子(TNF)-α水平。比较两组的出血量、手术时间、术后恶心呕吐和肩部疼痛发生率及肠鸣音恢复时间。结果非气腹组的术后肠鸣音恢复时间显著短于气腹组(P<0.05),术后恶心呕吐和肩部疼痛的发生率显著低于气腹组(P<0.05)。两组在各时间点的MAP、心率、SpO2的差异均无统计学意义(P值均>0.05)。非气腹组在不同时间点的CVP和呼吸动力学参数的差异均无统计学意义(P值均>0.05);气腹组在T2、T3时间点的CVP、气道峰压和气道平台压显著高于同组T1时间点及非气腹组相同时间点(P值分别<0.01、0.05),胸肺顺应性显著低于同组T1时间点及非气腹组相同时间点(P值均<0.05)。两组患者的pH值在麻醉开始后均有下降趋势,但与同组T1时间点的差异无统计学意义(P值均>0.05)。气腹组在T2、T3时间点的动脉血氧分压显著低于同组T1时间点及非气腹组相同时间点(P值均<0.05),动脉血二氧化碳分压显著高于同组T1时间点(P值均<0.05)。两组患者血皮质醇、IL-6和TNF-α水平在T2、T3、T4时间点逐渐升高,显著高于同组T1时间点(P值分别<0.01、0.05),气腹组在T2、T3、T4时间点的上述指标均显著高于非气腹组相同时间点(P值均<0.05)。结论在老年妇科手术中,与气腹腹腔镜手术相比,非气腹腹腔镜手术具有对呼吸、循环系统功能干扰小,应激反应轻,肠鸣音恢复快,术后恶心呕吐和肩部疼痛发生率低等优势,有利于患者的康复。

Objective To observe the effects of gasless laparoscopy on circulation, respiration, stress response and complications in gynecologic surgery in elderly patients. Methods Forty patients （American Society of Anesthesiologists grade Ⅱ- Ⅲ, 60 - 70 years old） scheduled for elective gynecological laparoscopic surgery were randomly divided into non-pneumoperitoneum group （NP, n = 20） and pneumoperitoneum group （P, n= 20）. After induction, the lung was initially ventilated in volume-controlled mode （tidal volume = 8 mL/kg, respiratory rate = 12 bpm, I ： E = 1 ： 2, fraction of inspired oxygen = 100 % ）. Monitoring parameters, such as mean artery pressure （MAP）, central venous pressure （CVP）, heart rate （HR）, saturation pulse oxygen （SpO2）, pulmonary compliance, peak air-way preasure （ppeak）, platform air-way preasure （ppla）, blood gas analysis （pH, pressure of arterial carbon dioxide [PaCO2], pressure of arterial oxygen [PaO2 ]）, serum cortisol, interleukin （IL）-6 and tumor necrosis factor （TNF）-α were recorded at the following 4 time points; after anesthesia （T1）,10 min after suspension/pneumoperitoneum （T2）, 30 min after suspension/pneumoperitoneum （T3） and 10 min after removal of suspension/pneumoperitoneum （T4）. Clinical data of the two groups including intraoperative blood loss, operation time, postoperative nausea and vomiting, shoulder pain and the recovery time of bowel tones were analyzed. Results The recovery time of bowel tones and the incidence of postoperative shoulder pain, nausea and vomiting in NP group were significantly less than those in P group （ P 〈 0.05）. There were no significant differences in MAP, HR or SpO2 at different time points between two groups （P〉0.05）; neither were CVP and pneumodynamic parameters in NP group at different time points （P〉0.05）. CVP, Ppeak and Ppla in P group at T2 and T3 were significantly higher than those at T1（P〈0.01） and those in NP group at the corresponding time points （ P〈0. 05）. When it came to pulmonary compliance, this trend was the opposite （ P〈0. 05）. The pH was slightly decreased in both two groups during the operation and was not significantly different with the value at T1 （ P 〉 0.05）. The levels of PaO2 in P group at T2 and T3 were significantly lower than those at T1 and those in NP group at the corresponding time points （P〈0.05）. Meanwhile, PaCO2 at T2 and T3 was significantly higher than that at T1 in P group （P〈0. 05）. As surgery going, the concentrations of cortisol, IL-6 and TNF-α increased gradually in both two groups, and the above-mentioned parameters at T2, T3 and T4 were significantly higher than those at T1 （ P〈0. 01, P〈0. 05）. Furthermore, these parameters in P group were significantly higher than those in NP group at T2, T3 and T4 （P〈0.05）. Conclusion Compared with non-pneumoperitoneum laparoscopic surgery, gasless laparoscopy has less influence on respiratory and circulatory functions, slighter stress response, shorter recovery time of bowl tones, and lower incidence of should pain, nausea and vomiting after surgery for elderly patients, which is beneficial for recovery of patients.