腹腔镜下子宫全切除/次全切除手术并发症的原因分析及防治

Analysis and Prevention of Complications of Total Laparoscopic Hysterectomy and Laparoscopic Subtotal Hysterectomy

目的 探讨腹腔镜下子宫全切/次全切除手术并发症的原因和防治措施.方法 对2004年1月-2010年10月2475例腹腔镜下子宫全切/次全切除手术的临床资料进行回顾性分析.结果 发生并发症279例（11.3%）,其中出血10例、肠道热灼伤4例、膀胱损伤1例、输尿管损伤1例、皮下气肿118例、感染10例、神经损伤7例、术后肩痛114例、暴露性角膜炎5例、皮肤电损伤5例、输卵管自阴道切缘脱出1例、切口疝3例.并发症中开腹处理1例,再次腹腔镜手术7例.2004-2006年并发症234例,手术并发症发生率31.4%（234/746）,2007-2010年并发症45例,手术并发症发生率2.6%（45/1729）.279例并发症中,以皮下气肿和术后肩痛多见,其中204例发生在前三年,28例发生在后四年,发生率分别为27 3%（204/746）、1.6%（28/1729）.结论 手术操作技术不成熟、腹腔镜开展初期、术中视野暴露不佳、穿刺口过大、未辨清解剖结构盲目操作、盆腹腔严重粘连、切口异物污染、腹腔内气体残留、穿刺口未避开腹壁血管是发生并发症的关键.

Objective To study the cause and prevention of complications of total laparoscopic hysterectomy and laparoscopic subtotal hysterectomy. Methods A retrospective study was carried out on the clinical data of 2,475 patients undergoing gynecological laparoscopic surgery in our hospital from January 2004 to October 2010. Results A total of 279 （ 11. 3% ） complications occurred, including 10 cases of hemorrhage, 4 cases of intestinal injury, 1 case of bladder injury, 1 case of ureteral injury, 118 cases of subcutaneous emphysema, 10 cases of pelvic infection, 7 eases of neural injury, 114 cases of shoulder pain,5 cases of exposure keratitis, 5 cases of skin electric injury, 1 case of fallopian tube prolapsed from vaginal incision and 3 cases of incisional hernia. Among these complications,laparotomy was required in 1 case,and second laparoscopic surgery was needed in 7 cases. There was 234 cases of complications from 2004 to 2006, with an incidence of 31. 4% （234/746） while from 2007 to 2010, 45 complications occurred, with an incidence of 2. 6% （45/1729）. Subcutaneous emphysema and shoulder pain were the main complications, and the incidences of both complications were 27.3% （204/746） from 2004 to 2006 and 1.6% （28/1729） from 2007 to 2010, respectively. Conclusion The causes of complication are summarized as follows： unskilled surgical techniques, early stage of laparoscopic surgery, poor exposure of surgical field, wide puncture, rash operation without distinguishing anatomic structure, severe adhesions of abdominopelvic cavity,incision contamination, gas residual in peritoneal cavity, and adjacency of puncture site to parietal vessels.