完全腹腔镜重度以上脾肿大切除术的临床研究

A clinical research of completely laparoscopic splenectomy for severe splenomegalia

摘要：目的探讨完全腹腔镜重度以上脾肿大切除联合门奇静脉断流术治疗门静脉高压症的手术技巧和可行性。方法对2009年3月～2012年11月在该科住院的33例门静脉高压症致重度以上脾肿大患者应用超声刀及血管闭合切割系（Ligasure），在完全腹腔镜行重度以上脾切除联合门奇静脉断流术治疗。结果30例完成腹腔镜手术（其中28例应用二级脾蒂离断法处理脾蒂），3例因术中大出血中转开腹。30例完全腹腔镜手术患者的手术时间为145～320min，平均200mill；术中失血量150～1200mL，平均450mL；门静脉血栓形成6例，术后发生少量腹水（〈300mL）S例，轻度胰瘘（〈10mL／d）4例，少量胸腔积液（〈300mL）3例。膈下脓肿1例。术后住院时间7—16d，平均8d。33例患者术后平均随访8个月（4～24个月），无再出血及死亡病例。结论完全腹腔镜重度以上脾肿大切除联合门奇静脉断流术治疗门静脉高压症微创伤、有效、安全，具有一定的临床推广价值。

[ Objective ] To evaluate the operative technical and feasibility of completely laparoscopic splenecto- my combined with portal azygous disconnection for severe splenomegalia induced by portal hypertension. [ Methods ] Thirty three cases with severe splenomegalia induced by portal hypertension were treated by laparoscopic splenecto- my combined with portal azygous disconnection by ultrasound knife and ligasure in our department from March 2009 to November 2011.[ Results ] Laparoscopic operation were accomplished in 30 cases. Of which 28 cases were dealed with second order spleen stem amputation and two cases were converted to open surgery due to intraoperative big bleeding. The operative time was 145 to 320 minutes（average 200 minutes）. The intraoperative blood loss was 150 to 1 200 mL（average 450 mL）. The postoperative complications included thrombosis of portal vein in six cases, manipu- lus ascites（〈300 mL） in five cases, mild pancreatic fistula（〈10 mL/d） in four cases, mild pleural effusion（〈300 mL） in three cases, and subdiaphragmatic abscess in one case. Length of stay after operation was seven to sixteen days（av- erage eight days）. Follow up was conducted in 33 cases for 4 to 24 months（average eight months）. There were no re- haemorrhagia and mortality occurred. [ Conclusion ] Completely laparoscopic splenectomy combined with portal azy- gous disconnection is microwounded, effective and relatively safe in treatment of severe splenomegalia induced by portal hypertension. There are considerable clinical promotion value.