改良腹腔镜巨脾切除术治疗儿童血液病的临床研究

The dinie research of the modified laparoscopic splenectomy for massive splenomegaly in the treatment of children with hematologic diseases

目的总结改良的腹腔镜辅助下巨脾切除术治疗儿童血液病的经验和特点。方法回顾性分析2007年3月至2011年12月30例行腹腔镜巨脾切除术的血液病患儿的临床资料。其中男性18例，女性12例；年龄2～14岁。原发病包括地中海贫血17例、遗传性球形红细胞增多症4例、原发性血小板减少性紫癜9例。采用改良的腹腔镜辅助下巨脾切除术：双重夹闭脾动脉暂不切断，分离完毕、脾血充分回流后，再将脾脏完全游离。记录患者手术及并发症情况，术后1周复查血红蛋白及血小板计数。结果26例顺利完成手术；中转开腹4例，其中2例特发性血小板减少性紫癜因接受激素治疗后过于肥胖而致术中暴露差，1例B型地中海贫血因合并肝重度肿大致腹腔内操作不便，1例为脾栓塞术后因脾周粘连严重术中分离时出血量较多。手术时间110～130min，平均120min。术中出血量35～100ml，平均45ml。患儿术后恢复顺利，平均住院时间5d。与术前相比，术后1周患者血红蛋白及血小板计数明显改善。结论改良腹腔镜巨脾切除术使许多过去认为难以实施的伴巨脾的血液病患儿的腹腔镜手术成为了可能。

Objective To summarize the experience and characteristics of the modified laparoscopic splenectomy for massive splenomegaly in the treatment of children with hematologic disease. Methods The clinical data of 30 cases of laparoscopic splenectomy for massive splenomegaly of children with hematologic disease from March 2007 to December 2011 was analyzed retrospectively. There were 18 male and 12 female patients, aging from 2 to 14 years. Primary disease included mediterranean anemia （ 17 cases）, hereditary spherocytosis （4 cases） and idiopathic thrombocytopenic purpura （ITP, 9 cases）. Dissection started with cutting off the gastrosplenic ligaments and lesser sac to fully reveal the splenic hilum, the splenic artery was clamped twice with 10 mm tiatanum clamp. When most of blood stored in the spleen back to heart through the veins and the splenic volume had already decreased, the splenic vein was ligated with 10 mm titanium clip and cut with ligsure and splenic pedicle separated. The Surgery and complication were recorded. For 1 week after surgery, the hemoglobin and platelet counts were reviewed. Results Twenty-six cases were performed successfully, and 4 cases were converted to open procedure. Of the 4 cases, 2 cases was obesity because of idiopathic thrombocytopenic purpura, 1 case was [3 thalassaemia combined severe liver enlargement, and l case was after partial splenic embolization. In cases of laparoscopic splenectomy, operation time was 110 to 130 minutes, with an average of 120 minutes, and blood loss during operation was 35 to 180 ml, with an average of 45 ml. Compared with pre-operation, the hemoglobin of mediterranean anemia and hereditary spherocytosis patients were （ 92 ±8 ） g/L, and blood platelet count of ITP patients was （127 ± 20） x 109/L, and they increased obviously at 1 week after operation （t = 4. 175 and 8. 253, both P = 0. 000 ）. Conclusion The modified surgical method make the laparoscopic splenectomy for massive splenomegaly in many children with hematologic diseases possible, which was thought to be impossible in the past.