自发性气胸胸腔镜辅助肺大疱切除术后松解下肺韧带的临床意义

Clinical significance of dissection of pulmonary ligament for the video assisted thoracic surgery with bullectomy for spontaneous pneumothorax

目的探讨自发性气胸胸腔镜辅助（VATS）肺大疱切除术中松解下肺韧带后的临床意义。方法回顾性分析2012年1月至2013年12月，232例因自发性气胸／血气胸接受VATS肺大疱切除术患者资料，男188例，女44例；年龄（26．4±10．1）岁。气胸肺大疱破裂部位202例位于肺尖部或靠近肺尖部，23例为肺下叶靠胸壁外侧缘，血气胸7例，其中复发再人院18例（7．7％，18／232）。所有患者分别接受了VATS肺大疱切除松解或未松解下肺韧带手术。结果松解组中112例肺尖部肺大疱切除者术后第1天胸腔积液量〈300ml者92例（82．1％，92／112），≥300ml者20例（17．9％，20／112），引流量（147．04-61．0）ml；术后第3天无胸腔积液／〉300ml者，引流量（33．4±20．0）ml；23例下叶肺大疱切除者术后第1、3天引流量分别为（155．2±41．1）ml和（52．1±21．3）ml。未松解组中，90例肺尖部肺大疱切除者术后第1天胸腔积液量〉300ml者81例（90％，81／90），〈300ml者9例（10％，9／90），平均引流量（65．1±28．0）ml；术后第3天，引流量（40．2±25．5）ml，胸腔积液≥300ml者40例（44．4％。40／90），肺复张良好。7例血气胸患者中未分析术后引流量，2例为下肺韧带撕裂损伤下肺血管分支所致。结论行VATS肺大疱切除术时，松解下肺韧带对患者术后充分引流、减少胸腔积液、促进胸膜粘连及预防再发气胸／血气胸有临床意义，而在导致支气管变形、肺不张及减少术后残腔等方面无明显临床意义。

Objective To evaluate the clinical significance of dissection of pulmonary ligament was operated on videoassisted thoracic surgery（VATS） with bullectomy for spontaneous pneumothorax. Methods From Jan 2012 to Dec 2013, 232 patients（ 188 males, 44 females） underwent VATS with bullectomy for spontaneous pneumothorax or hemopeumothorax, whose age were between 14 and 45 years and mean age was（26.4 ± 10.1 ） years. 202 patients resulted from upper lobe spontaneous pneumothorax, 23 patients for lower lobe spontaneous pneumothorax, 7 patients for hemopeumothorax, and 18 cases because of recurrence after bullectomy （7.7 %, 18/232）. all the patients were accepted bullectomy with or without dissection of pulmonary ligament. Results Between 112 patients who underwent upper lobe bullectomy with dissection of pulmonary ligament, at i st postoperative day, it was found 92 patients whose pleural effusion were less than 300 ml （82.1%, 92/112 ） ; 20 patients whose pleura] effusion were greater than or equal to 300 ml（ 17.9%, 20/112 ）, and the mean drainage from thoracic cavity was （ 147.0 ± 61.0） ml. At 3rd day, the mean drainage was（33.4 ± 20.0） ml . Within 23 cases who underwent lower lobe bullectomy with dissection of pulmonary ligament, the mean drainage from thoracic cavity, at 1st postoperative day, was（ 155.2 ± 41.1 ）ml, and the mean drainage, at the 3 rd day, was （52.1 ± 21.3 ） ml . Also, within 90 patients who underwent bullectomy without dissection of pulmonary ligament, 9 patients whose pleural effusion, at 1 st postoperative day, were less than 300ml （10% ,9/90） ; 81 patients whose pleura] effusion were greater than or equal to 300ml （90% , 81/90 ） ; the mean drainage for 90 patients was （65.1 ±28.0 ） m]. At the 3 rd day, 40 patients＇ pleural effusion were greater than or equal to 300ml （44.4% , 40/90） , and the mean drainage was（40.2 ±25.5） ml. 2 of 7 hemopeumothorax patients bled for the vessels injury during pulmonary ligament avulsion. Conclusion There was significant difference in clinical outcomes between two groups, and the dissection of pulmonary ligament was able to reduce the pooling of pleural effusion, facilitate the drainage of pleural effusion, and prevent pneumothorax recurrence, but there is no convincing evidence that dissection of pulmonary ligament can lead to bronchial deformation, stenosis, and reduce the free thoracic space.