腹腔镜诊治复杂型肠旋转不良七例

Laparoscopic diagnosis and treatment of complex intestinal malrotation： a report of 7 cases

目的报道腹腔镜诊治复杂型肠旋转不良7例，探讨腹腔镜诊治复杂型肠旋转不良的初步经验及可行性。方法回顾性分析2011年6月至2014年1月应用腹腔镜诊治复杂型肠旋转不良患儿7例的资料。采用4孔法。其中2例松解ladd’s韧带后提示并环状胰腺，行腹腔镜ladd’s手术及十二指肠菱形吻合术；合并左侧急性阑尾炎穿孔1例，行腹腔镜ladd’s手术、阑尾切除术及腹腔冲洗及引流术；合并乳糜腹1例，行ladd’s手术及腹腔冲洗及引流术；合并左侧Amyand’s疝1例，行ladd’s手术及左侧腹股沟斜疝疝囊高位结扎术；Waugh’s综合征1例，行腹腔镜下肠套叠复位及ladd’s手术；合并十二指肠闭锁、空肠多发性闭锁1例，明确诊断后中转开放手术。结果本组7例均在腹腔镜下明确诊断，其中6例在腹腔镜下完成手术，手术时间为90-150min（平均125min）。术中出血2～10ml，无术中输血病例，未出现术中并发症。术后3～13d（平均5．4d）进流质饮食，8～16d（平均11d）出院。现术后随访2～20个月（平均7．8个月），1例合并乳糜腹患儿术后2个月出现不全性肠梗阻，经保守治疗获愈。其余患儿疗效满意。结论复杂型肠旋转不良可以通过腹腔镜明确诊断并确定术式。腹腔镜治疗小儿肠旋转不良安全可靠，对患儿打击小，必要时及时中转开放手术。

Objective To summarize our preliminary experiences of laparoscopic diagnosis and treatment for complex intestinal malrotation. Methods A retrospective review was performed for the laparoscopic diagnosis and treatment for 7 children of complex intestinal malrotation from June 2011 to January 2014. Their mean age was 9. 3 months （1 day to 4 years） and their minimum weight 2. 5 kg. A 5-ram port was placed at umbilicus for a 300 laparoscope and the second and third ports were inserted at the right lower and upper abdomen just lateral to the edge of rectus abdominis muscle. An extra port could be placed in left upper quadrant for aiding operation. Two cases were complicated with annular pancreas. And Ladd＇s procedure and duodenal diamond anastomosis were performed; one case was complicated with left-sided perforated appendicitis. And Ladd＇s procedure, appendectomy, peritoneal lavage and drainage were accomplished laparoscopiclly; One case was complicated with Amyand＇s hernia. And Ladcts procedure, appendectomy and herniorrhaphy were performed; one case was associated with Waugh＇s syndrome. And laparoscopic reduction of intussusception and Ladd＇s procedure were accomplished; one case complicated with duodenal atresia and multiple jejunal atresias converted into open surgery. Results All cases were diagnosed laparoscopiclly and 6 of them underwent laparoscopy. The mean operative duration was 125（90-150） min. Intraoperative bleeding volume was 2-10 ml without necessity for blood transfusion or intraoperative complications. Feeding was started at a mean of postoperative day 5.4 （3-13）. Discharge was made at a mean of postoperative day 11 （8-16）. The mean follow-up period was 7. 8 （2-20） months. One case of chylous ascites complicated with incomplete intestinal obstruction at 2 months post-operation was cured conservatively. And the remainder recovered well. Conclusions Diagnosis and operating method may be determined laparoscopically. Laparoscopic Ladd＇s procedure is both effective and safe. And conversion into open surgery is adopted when it is necessary.