直肠癌术中盆腔大出血的预防和处理

Prevention and Management of Massive Pelvic Hemorrhage in Radical Operations for Rectal Carcinoma

介绍直肠癌根治手术中防治盆腔大出血的处理经验。方法：1993年8月～2000年4月，共完成直肠癌根治手术627例。术中因血管损伤而发生大出血者12例，计骶前静脉丛6例、骶椎静脉1例、前列腺静脉丛2例、髂内动静脉分支2例，髂总静脉1例。防治方法：术者应掌握盆腔解剖，力求沿间隙操作，保护好骶前静脉丛，沿髂内动脉内侧镰状筋膜处理侧韧带。肿瘤浸润阴道或前列腺时可边切除边缝合，盆腔侧壁轻度浸润者可在侧方淋巴结清除的同时，合并髂内动静分支结扎。发生盆腔大出血时，应根据出血部位和肿瘤情况，分别选用骶丛止血钉按压法、纱布压迫止血法、缝扎止血法或血管修补术。结果：本组出血率1.91%，失血量<150ml者5例，150～500ml6例，>500ml者1例。应用骶丛止血钉按压止血4例，纱布压迫止血法3例，髂内动脉分支缝扎2例，骶前缝扎止血2例，静脉修补术1例。发生出血之病例中有Miles手术3例，保肛手术9例，无手术中死亡。结论：直肠癌根治手术时按解剖层次正确操作可防止盆腔大出血。万一发生盆腔大出血时，可选用骶丛止血钉、纱布压迫、缝扎止血或血管修补术等方法。

To summarize the experience in the management of massive pelvic hemorrhage during radical operations for rectal carcinoma. Methods: From August 1993 to April 2000, 627 patients underwent radical operations for rectal carcinoma. Massive pelvic hemorrhage occurred in 12 cases, including injury of the presacral venous plexus in 6 cases, of the sacral intervertebral vein in 1 case, of the branches of internal iliac artery or vein in 2 cases, of the common iliac vein in 1 case. Prophylaxis and treatment: The operator should master the anatomy of pelvic cavity, dissect alongside anatomical spaces, protect well the presacral venous plexus, and manage the lateral ligament close to the falciform fascia, medial to the internal iliac artery. If the vagina or the prostate is infiltrated, resection is carried out by cutting and suturing alternatively. If the pelvic wall is slightly involved, branches of the internal iliac artery and/or vein should be ligated while excising the lymph nodes. Hemostatic nail pressing, sponge pressing, blood vessel transfixion-suture, or angiorrhaphy could be used according to the site and the severity of the hemorrhage. Results: The rate of massive hemorrhage was 1.91% in this series. The amount of bleeding volume was less than 150ml in 5 cases, 150～500ml in 6 cases and >500ml in 1 case. The Miles procedure was performed in 3 cases and sphincter-preserving operations in 6, no mortality occurred during surgery. Conclusions: Dissection according to anatomy is recommended in order to prevent massive pelvic hemorrhage during radical surgery for rectal carcinoma. Nail pressing, sponge pressing and angiorrhaphy could be selectively used while massive hemorrhage occur.