腹腔镜五步法脾切除联合贲门食管周围血管离断术

Laparoscopic five-stage splenectomy plus pericardial devascularization for the treatment of portal hypertension

目的：探索腹腔镜下脾切除联合贲门食管周围血管离断术的操作方法。方法：回顾分析2011年4月至2014年4月为22例肝硬化门脉高压症患者行腹腔镜脾切除加贲门食管周围血管离断术的临床资料，术中采用五步法腹腔镜脾切除加贲门食管周围血管离断术。结果：前3例患者手术时间约为270min，后19例为180～240min，平均（210±30）min；术中平均出血（150±100）ml。1例腹腔粘连严重，中转开腹。17例肝结节样增生严重，同时取肝组织活检。并发呼吸道感染4例，腹水增多1例。术后肠道功能恢复时间16～72h，平均（36±12）h；下床时间8～36h，平均（24±6）h；术后住院7～14d，平均（10±3）d。术后随访1个月-2年，1例术后病检证实为原发性肝癌，二期转外院行手术治疗，随访2年，至今仍健在。7例肝功能B级患者，术后3个月复查肝功能全部逆转恢复至A级。术后迄今为止无再出血病例。结论：五步法腹腔镜脾切除联合贲门食管周围血管离断术优化了手术流程，降低了手术难度，值得临床推广应用。

Objective：To investigate the technique of laparoscopic five-stage splenectomy plus pericardial devascularization in the treatment of portal hypertension due to liver cirrhosis. Methods ： Clinical data of 22 patients with portal hypertension due to liver cir- rhosis ,who underwent laparoscopic five-stage splenectomy plus pericardial devascularization from Apr. 2011 to Apr. 2014 ,were analyzed retrospectively. Results：The operative time was about 270 min for the first three cases, but later the operative time was reduced to （210 ± 30） min （ range ： 180-240 min） for other 19 cases. The mean intraoperative blood loss was （ 150 ± 100 ） ml. One case was converted to open surgery due to severe abdominal adhesion. Liver biopsy was performed in 17 cases. Perioperative complications occurred in five cases （4 cases of respiratory infection, 1 case of increased ascites）. The mean time to recovery of gastrointestinal function was （ 36 ± 12） h （ ranging from 16 to 72 h）, and the mean time to ambulation was （24 ± 6） h （ ranging from 8 to 36 h）. The mean hospitalization was （ 10 ±3） d （range：7-14 d）. The patients were followed up for 1 month to 2 years. One case was confirmed as primary hepatocellu- lar carcinoma by postoperative biopsy, and transferred to other hospital for further surgery. In 3 months, liver function recovered from Child-Pugh stage B to stage A in 7 cases. Till now no patients had gastrointestinal hemorrhage again. Conclusions ： Laparoscopic five- stage splenectomy plus pericardial devaseularization improves the procedures of surgery in the treatment of portal hypertension, and re- duces surgical difficulty. This oroeedure deserves to be recommended in the clinical application.