腹腔镜阑尾切除术后再手术原因分析

An Analysis of the Causes of Laparoscopic Appendectomy Failure

目的 分析腹腔镜阑尾炎手术后再手术的原因,探讨腹腔镜阑尾炎手术中应注意的事项.方法 2003年5月~2013年3月,发生11例腹腔镜阑尾切除术后再手术.急性阑尾炎10例,慢性阑尾炎1例.再手术原因：腹腔脓肿4例,回盲部肿瘤1例,腹腔大出血并休克1例,腹膜后血肿1例,小肠漏1例,肠粘连1例,盆腔炎1例,胰腺炎1例.经保守治疗无效,8例行腹腔镜探查,3例开腹探查.结果 二次手术均成功.腹腔脓肿4例行腹腔镜脓肿清洗引流,腹腔大出血并休克1例行腹腔镜探查腹壁下动脉结扎,肠粘连1例行腹腔镜探查粘连带松解,盆腔炎1例行腹腔镜盆腔冲洗引流＋抗感染治疗,胰腺炎1例行腹腔镜胰腺被膜打开胰腺周围置管引流;小肠漏1例行腹腔镜探查＋开腹小肠肠管部分切除吻合术,腹膜后血肿1例行开腹探查阑尾动脉结扎,回盲部肿瘤1例行开腹右半结肠切除术（病理高分化腺癌）.术后7~21天痊愈出院.结论 腹腔镜下阑尾切除术后再手术的原因为：术前术中漏诊、误诊;术中脓液清洗不彻底,术后引流不通畅致腹腔脓肿形成;术中操作不规范,致腹壁下血管、阑尾动脉出血.腹腔镜阑尾切除术应注意规范操作,术中应探查仔细,防止漏诊、误诊.

Objective To analyze the causes of failure of laparoscopic surgery for patients with appendicitis, and explore the precautionary measures in laparoscopic appendectomy. Methods From May 2003 to March 2013, 11 cases undergoing laparoscopic appendectomy required a secondary operation, including 10 cases of acute appendicitis and 1 case of chronic appendicitis. The secondary operation included 4 cases of abdominal abscess, 1 case of ileocecal tumor, 1 case of abdominal hemorrhage and shock, 1 case of retroperitoneal hematoma, 1 case of intestinal leakage, 1 case of intestinal adhesion, 1 case of pelvic inflammation, and 1 case of pancreatitis. After the failure of conservative treatment, $ cases underwent laparoscopic exploration, and 3 cases received laparotomy. Results All the secondary operations were successful. The 4 cases of abdominal abscess received drainage and cleaning of abdominal abscess, the 1 case of intraperitoneal hemorrhage and shock received abdominal wall artery ligation via laparoscopic exploration, the 1 case of intestinal adhesion received lysis of adhesions with laparoscopy, the 1 case of pelvic inflammation received laparoscopic pelvic drainage and anti-infection treatment, the 1 case of pancreatitis underwent capsule of pancreas open and peripancreatic drainage laparoscopically; the 1 case of intestinal leakage underwent laparoscopic exploration and open intestine part resection and anastomosis, the 1 case of retroperitoneal hematoma underwent exploratory laparotomy appendiceal artery ligation, and the 1 case of ileocecal tumor underwent open right hemicolectomy （ pathological diagnosis was well differentiated adenocarcinoma）. Postoperative stay of the patients were 7 -21 days. Conclusion The causes of re-operation after laparoscopic appendectomy are： preoperative and intraoperative missed diagnosis and misdiagnosis; incomplete intraoperative pus cleaning and obstructed drainage which induces postoperative intra-abdominal abscess; lower epigastric vessels and appendicular artery bleeding caused by nonstandard operation. Accurate operation and scrutinized exploration are required in laparoscopic appendectomy to prevent missed diagnosis and misdiagnosis.