腹腔镜探查与治疗在腹部损伤中的应用要点分析

Laparoscopic Approach and Treatment:Application in Abdominal Trauma

目的：分析腹腔镜技术在腹部创伤诊断及治疗中的应用要点。方法回顾性分析2007年6月-2013年6月南方医科大学附属小榄医院利用腹腔镜技术诊治腹部损伤患者50例。收集患者临床资料，包括腹部损伤类型、致伤原因、损伤部位及腹部立位平片或 CT结果，并对其进行统计描述。结果腹部损伤类型：闭合性创伤45例（90.0%），开放性锐器伤5例（10.0%）。致伤原因：车祸伤29例（58.0%），高处坠落伤9例（18.0%），刀刺伤5例（10.0%），棍击伤3例（6.0%），重物压伤2例（4.0%），拳脚伤2例（4.0%）。腹部损伤部位：单纯腹壁伤5例（10%，含大腿外侧至对侧腹壁的长距离隧道式伤口1例），大网膜血肿5例（10.0%），肠系膜血肿5例（10.0%），肝挫裂5例（10.0%），脾挫裂12例（24.0%，合并小肠破裂、结肠破裂、左肾挫伤各1例），肾挫裂2例（4.0%），小肠破裂10例（20.0%，单处裂伤7例、2处以上裂伤或断裂3例），十二指肠破裂1例（2.0%），胃破裂2例（4.0%，胃前后壁破裂1例），胃破裂合并肝左外线状裂伤1例（2.0%），右肝脏面裂伤并胆囊破裂1例（2.0%），结肠破裂3例（6.0%），胰腺损伤1例（2.0%），膀胱损伤1例（2.0%），膈肌破裂并肝脏面裂伤1例（2.0%），腹膜后血肿1例（2.0%），其中2个器官损伤4例（8.0%），3个以上器官损伤1例（2.0%）。腹部立位平片或CT平扫提示腹腔游离气体8例，占空腔脏器破裂（17例）的47.1%；CT检查提示血肿、实质性脏器损伤30例，占实质性脏器（33例）的91.0%。50例（100.0%）经腹腔镜探查确诊，其中38例（76.0%）在腹腔镜或其辅助下完成手术治疗，12例（24.0%）中转开腹手术；手术时间35-200 min，平均（65.0±15.0）min；出血量10-600 ml，平均（100.0±35.0）ml；住院时间3-25 d，平均（7.0±1.5）d。术后2周内出现肠粘连梗阻、再出血、切口感染、盆腔脓肿各1例，均经保守治疗痊愈；最终患者均治愈出院，无腹腔内大出血、消化道瘘、多器官功能障碍等严重并发症及围术期死亡。结论腹腔镜探查对腹部创伤的诊断率较高，可减少二次损伤和阴性探查，可同时处理或辅助处理伤情，具有明显优势；但其在适应证、禁忌证、中转开腹等方面应遵循相应原则。

Objective To analyze the application of laparoscopic approach in the diagnosis and treatment of abdominal trauma（ AT）. Methods The clinical data of 50 AT patients（ types,causes,sites of injuries,erect abdominal plain films or CT results）in Xiaolan Hospital Affiliated to Southern Medical University from June 2007 to June 2013 were analyzed retrospec-tively and described statistically. ResUlts Types of AT：45 cases of blunt trauma （ 90. 0%）, 5 open sharp injuries （10. 0%）. The causes of injuries：29 cases of traffic accident（58. 0%）,9 falls injuries（18. 0%）,5 stabbing injuries （10. 0%）,3 stick-beating injuries（6. 0%）,2 weight-crushing injuries（4. 0%）,2 fist injuries（4. 0%）. Sites of AT：5 cases of simple abdominal wall injuries（10. 0%）,5 omentum hematoma（10. 0%）,5 mesenteric hematoma（10. 0%）,5 liver laceration（10. 0%）,12 spleen laceration（24. 0%）,2 renal laceration（4. 0%）,10 small bowel（20. 0%）,1 duo-denal rupture （ 2. 0%）,2 stomach rupture （ 4. 0%）,1 stomach rupture combined with hepatic left lateral linear laceration （2. 0%）,1 right liver laceration complicated by rupture of gallbladder（2. 0%）,3 colon rupture（6. 0%）,1 pancreatic inju-ry（2. 0%）,1 bladder injury（2. 0%）,1 rupture of diaphragm combined with liver laceration（2. 0%）,1 retroperitoneal he-matoma（2. 0%）. Four patients had 2 organic damages（8. 0%）,1 had 3 or more（2. 0%）. Erect abdominal plain films showed 8 cases of peritoneal cavity free air,account for 47. 1% of the 17 cases of viscus rupture;CT showed 30 cases of hemato-ma,substantial organ damages,accounting for 91. 0% of substantial viscus rupture（33 cases）. Fifty patients were diagnosed by laparoscopy（100. 0%）,38 patients completed surgeries under laparoscopy or with its help（76. 0%）,12 converted to lap-arotomy（24. 0%）;the operation time was 35 to 200 min,averagely（65. 0 ± 15. 0）min;blood loss was 10 to 600 ml,mean-ly（100. 0 ± 35. 0）ml;hospital stay was 3 to 25 d,averagely（7. 0 ± 1. 5）d. One patient had ankylenteron obstruction,1 had rehaemorrhagia,1 had wound infection,1 had pelvic abscess,who were all cured after conservative treatment and dis-charged ultimately,without such severe complications as abdominal bleeding,gastrointestinal fistula,multiple organ dysfunc-tion,etc. or perioperative mortality. ConclUsion Laparoscopy makes a high diagnostic rate for AT,can reduce secondary dam-ages and negative probes. But physicians should follow appropriate principles in indications,contraindications,conversion to laparotomy,etc.