腹腔镜Ladd手术治疗肠旋转不良的探讨

Laparoscopic Ladd's Procedure for the Treatment of Congenital Intestinal Malrotation

目的探讨腹腔镜Ladd手术治疗肠旋转不良的手术效果。方法 2008年8月～2012年8月,行腹腔镜Ladd手术8例,年龄1个月～3岁,平均1.6岁。经脐、右上腹和右中腹置入3个5 mm trocar,将回盲部肠管推向左侧腹,寻找并确定Ladd韧带电钩离断,充分游离十二指肠解除压迫。自近端空肠逐步向远端小肠探查,并使扭转肠管复位。从回盲部向肠系膜根部切开肠系膜前叶的脏层腹膜,将十二指肠顺脊柱右侧下行,小肠置于腹腔右侧,结肠置于腹腔左侧。腹腔镜下或经脐部trocar提出阑尾切除。结果 8例均经腹腔镜探查证实为肠旋转不良,其中5例合并中肠顺时针扭转。均在腹腔镜下予以复位并顺利完成Ladd手术,手术时间60～150 min,平均100 min,术中出血<10 ml。1例探查过程中发现合并空肠异位胰腺,经扩大脐部戳孔后提出腹外切除。术后留置胃管1～3 d,拔出后恢复饮食,无手术并发症。术后住院4～6 d。随访2个月～2年,平均15个月,其中5例>12个月。患儿生长发育良好,无不适症状。结论腹腔镜Ladd手术治疗肠旋转不良疗效确切,具有创伤小、进食早、恢复快等优点。

Objective To evaluate the effectiveness of laparoscopic diagnosis and treatment for intestinal mal-rotation. Methods From August 2008 to August 2012, 8 children （ M/F： 6/2） who underwent laparoscopic Ladd＇ s procedures for intestinal mal-rotations were evaluated. The average age at operation was 1.6 years （ 1 month - 3 years）. Three trocars of 5 mm were inserted through umbilicus, right upper and middle abdomen. The ileocecal intestinal canal was pushed to left abdomen, the ladd ligature was dissected by electro-hook and the duodenum was completely dissected. The mal-rotated intestine was restored to normal location. Visceral peritoneum of mesenteric lobus anterior was cut from ileocecal junction to mesenteric root. The duodenum was down along the right side of the spine, the small intestine was put in the right side of the enterocoelia and colon was put in the left side of the enterocoelia. The laparoscopic or troear appendectomy was performed concurrently. Results 8 patients were confirmed by laparoscopic examination as intestinal malrotation, including 5 cases of clockwise torsion. Ladd procedure was performed and the intestine was restored via laparoscopy for all cases. The average operative time was 100 rain （range：60 - 150 min）. Mean blood loss was less than 10 ml. Combined jejunal ectopic pancreas was found in one patient, and was resected outside the abdominal wall. Postoperative gastric intubation remained for 1-3 d and no complications were found after the extraction. Postoperative hospital stay was 4-6 d. All the patients were followed up for 2-24 months （mean：15 months） , including 5 cases for more than 12 months. All patients recovered well. Conclusion Neonatal intestinal mal-rotation can be treated by laparoscopy safely. Compared to open procedures, patients had earlier food intake, shorter hospital stay and less scars.