心脏机械瓣置换术后患者行妇科腹腔镜手术的可行性分析

Feasibility of gynecological laparoscopy surgery for patients with mechanical heart valves

目的 探讨心脏机械瓣置换术后患者行妇科腹腔镜手术的安全性、可行性及围术期管理问题.方法 收集2008年1月至2014年5月76例心脏机械瓣膜置换术后在低流量（＜2 L/min）、低气腹压（8～ 12 mmHg,1 mmHg =0.133 kPa）条件下于首都医科大学附属北京安贞医院行妇科腹腔镜手术患者的临床资料.其中腹腔镜辅助阴式全子宫切除术27例,腹腔镜全子宫＆#177;双附件切除术15例,腹腔镜下子宫肌瘤剔除术6例,腹腔镜单侧附件切除术15例,腹腔镜下卵巢囊肿剥除术9例,腹腔镜下输卵管切除术4例.术前经过充分的评估,术中、术后观察手术时间、出血量、排气时间、住院时间;比较术前术后血红蛋白、国际标准化比值（INR）、D-二聚体、脑钠肽、超敏肌钙蛋白（hs-cTn）、左心室射血分数（LVEF）、跨瓣压差差异.围术期给予全面、细致的调整和管理.结果 76例患者均顺利完成手术,与子宫手术相比、附件手术的手术时间、出血量、排气时间、住院时间均较少.血红蛋白、INR、D-二聚体、脑钠肽、hs-cTn、LVEF、跨瓣压差在术前术后差异无统计学意义（P＞0.05）.术中、术后无心律失常、心功能不全、感染性心内膜炎、肺栓塞、下肢静脉血栓等不良事件发生,未发生腹腔内出血及切口渗血,切口均Ⅰ期愈合.术后随访6～24个月,所有患者心脏瓣膜状态良好、无血栓栓塞性疾病、出血性疾病,心功能无变化.结论 心脏机械瓣膜置换术后的患者经过充分的术前评估、科学的围手术期管理行腹腔镜手术是安全、可行的.

Objective To explore the safety,feasibility and perioperative management of gynecological laparoscopy surgery for patients with mechanical heart valves.Methods Totally 76 patients with mechanical heart valves from January 2008 to May 2014 underwent gynecological laparoscopy surgery [low flow （〈 2 L/min） and low pneumoperitoneum pressure （8-12 mmHg）].Twenty seven cases had laparoscopic assisted transvaginal hysterectomy;15 cases had laparoscopic hysterectomy and bilateral adnexectomy;6 cases had laparoscopic myomectomy;15 cases had laparoscopic unilateral adnexectomy;9 cases had laparoscopic ovarian cyst removal surgery;4 cases had laparoscopic salpingectomy.Indicators such as length of operation time,blood loss,exhaust time,days of hospital stay were observed during and after operation.The hemoglobin,international standardization ratio （INR）,D-dimer,brain natriuretic peptide （BNP）,high-sensitivity troponin （hs-cTn）,left ventricular ejection fraction （LVEF） and transvalve pressure were compared before and after operation.Perioperative management was carefully adjusted.Results The operations were all successfully performed.Compared with those in uterine operations,the length of operation time,blood loss,exhaust time and days of hospital stay in accessories operations were less.There were no statistical differences of hemoglobin,INR,D-dimer,BNP,hs-cTn,LVEF and transvalve pressure before and after operation （P 〉 0.05）.No adverse events including arrhythmia,cardiac dysfunction,infective endocarditis,pulmonary embolism,deep venous thrombosis occurred during and after operation.All the operative incisions were primary healing,with neither abdominal cavity internal hemorrhage nor incision bleeding.After 6-24 months,of follow-up,the heart valves were all in good condition;no thromboembolic or hemorrhagic diseases occurred and no changes of cardiac function were observed.Conclusion Gynecological laparoscopy surgery is safe and feasible for patients with mechanical heart valves.