标准化指征下胸腔镜手术治疗新生儿先天性膈疝

Outcomes of Thoracoscopic Repair of Congenital Diaphragmatic Hernia in Neonates Under Standardized Indications

目的探讨胸腔镜手术治疗新生儿先天性膈疝（congenital diaphragmatic hernia,CDH）的疗效。方法 2013年9月～2014年8月应用胸腔镜治疗新生儿先天性膈疝14例,观察孔位于肩胛下角第6肋间,置入5 mm trocar,操作孔2个,分别位于肩胛下角线与脊柱连线中点第5～7肋间和腋前线第5～7肋间,置入3 mm trocar;在6 mm Hg气压维持下,将疝内容物回纳,再降低压力至2～4 mm Hg,以不可吸收线完成膈肌修补。结果除1例因脾脏出血中转开腹外,其余13例均顺利完成胸腔镜手术。手术时间90～150 min（平均116 min）。术中监测血气,13例完成胸腔镜手术患儿术中Pa CO238～66 mm Hg（平均48 mm Hg）,p H 7.18～7.39（平均7.30）,乳酸0.55～1.22 mmol/L（平均0.93 mmol/L）。术后呼吸机通气时间49～192h（平均113 h）。14例随访2～13个月（平均7个月）,14例患儿均存活,无复发,1例术后5个月左侧肺炎,1例术后9个月因粘连性肠梗阻行手术治疗,余患儿均无呼吸困难、呼吸道感染症状或肠梗阻发生,生长发育良好。结论胸腔镜手术治疗新生儿CDH疗效满意。

Objective To analyze clinical outcomes of thoracoscopic repair of neonatal congenital diaphragmatic hernia （CDH）. Methods Clinical data of 14 patients with CDH receiving thoracoscopic repair from September 2013 to August 2014 were retrospectively analyzed. Thoracoscopic observation port was placed at the site of suhscapular angle on the sixth intercostal space for a 5 mm trocar. The two operational ports were located at the medium between scapular line and vertebral line on the level of fifth - seventh intercostal space and at the posterior axillary line on the level of fifth - seventh intercostal space, respectively, for 3 mm trocars. The CO2 pressure decreased to 2 - 4 mm Hg after reduction of herniated organ. The diaphragmatic defect was identified and repaired with prolene or polyester fiber interrupted sutures. Results Primary diaphragmatic repair was successfully accomplished under thoraeoscope in 13 neonates without perioperative complications, while one patient underwent conversion to open surgery because of spleen bleeding. In the 13 thoraeoscopic cases, the intraoperative PaCO2 was 38 -66 mm Hg （ average, 48 mm Hg） , the pH value was 7.18 -7.39 （ average, 7.30） , the lactate level was 0.55 - 1.22 mmol/L （ average, 0.93 mmol/L） , and the postoperative mechanical ventilation time was 49 - 192 h（ average, 113 h）. All the cases were followed up for 2 - 13 months （ average, 7 months）. One patient required reoperation for adhesive intestinal obstruction at 9 months after operation and one case suffered pneumonia at 5 months after repair. There were no other long-term complications. Conclusion Strictly following surgical indications for thoracoscopic repair of CDH in neonates could achieve satisfactory efficacy.