有腹部手术史患者腹腔镜术闭合法建立气腹方法探讨

The closed establishment of pneumoperitoneum for laparoscopic procedures in patients with a history of abdominal surgery

目的 探讨有腹部手术史患者腹腔镜术闭合法建立气腹的可行性及操作方法。方法回顾分析我院 1991年 9月至 1998年 12月 6 2 0 0例腹腔镜术中 96 3例有腹部手术史患者闭合法建立气腹成功的经验及 2例内脏损伤的教训 ;我们把建立气腹困难分为真性建立气腹困难及假性建立气腹困难两种。由气腹针穿入大网膜、肝圆韧带、肠系膜、腹膜外脂肪等引起的充气困难称假性建立气腹困难 ,而因气腹针穿入腹腔脏器 (如胃肠道、大血管 )或因腹腔内存在广泛粘连致气体膨胀困难引起的充气困难称为真性建立气腹困难。结果 6例患者因真性建立气腹困难、12例因假性建立气腹困难而中转开腹 ,闭合法建立气腹成功率为 98%。 2例胆囊结石患者因未遵循闭合法建立气腹原则致空肠或回肠损伤 ,立即开腹行肠修补、胆囊切除术。结论 绝大多数有腹部手术史患者闭合法建立气腹是安全可行的。遵循闭合法建立气腹原则 ,真性建立气腹困难时及时中转开腹是避免内脏损伤的关键。

Objective To investigate the feasibility and ways of closed establishment of pneumoperitoneum for laparoscopic procedures in patients with a history of abdominal surgery. [WT5”HZ]Methods[WT5”BZ] Between September 1991 and December 1998, 963 patients with a history of abdominal surgery received closed establishment of pneumoperitoneum. The difficulties with closed establishment were classified as false and real types. Veress needle penetrating into falciform ligament, mesentery, great omentum or retroperitoneal fat tissue caused false difficulty, while the difficulty due to Veress needle penetrating into abdominal viscera or because of extensive adhesion was known as real difficulty.[WT5”HZ] Results[WT5”BZ] 18 cases for false and real difficulty were transfered to open surgery.Two cases suffered visceral injuries for laparoscopic cholecystectomy, including jejunum and ileum injuries in one each case. The occurrence rate of visceral injuries accounted for 0 2% in this group.[WT5”HZ] Conclusion[WT5”BZ] This result demonstrates that closed establishment of pneumoperitoneum is safe and feasible in most patients with abdominal operative history. Abiding by the rule of closed establishment pneumoperitoneum and conversion to laparotomy in time in real difficulty is important to avoid visceral injuries.