腹腔镜完整结肠系膜切除术相关血管变异与术中出血的应对措施

Associated vessel heteromorphosis in laparoscopic complete mesocolic excision and solutions to intraoperative hemorrhage

腹腔镜完整结肠系膜切除术（CME）中，血管的辨识与解剖是关键步骤，若血管发生损伤，容易造成手术时间延长、术中出血增多以及吻合口缺血等并发症。在腹腔镜CME术中，肠系膜上动脉（SMA）、肠系膜上静脉（SMV）、胃结肠干血管、左结肠与乙状结肠动脉以及结肠边缘血管弓均可存在不同程度的血管变异，对手术操作造成一定的影响并提出更高的要求。术中需仔细辨认可能存在变异的血管并及时调整手术策略。术前通过腹部CT血管成像及三维重建技术，可提前了解术区血管走行以及是否存在血管变异；术中尽可能显露静脉的结构，避免粗暴分离操作，减少出血且利于止血；当术中发生出血时，应根据不同的出血状况，选择压迫或使用血管夹闭器材等止血手段；当出血量较多，腹腔镜下止血存在困难时，果断中转开腹，不要犹豫。

Vessel identification and dissection are the key processes of laparoscopic complete mesocolic excision （CME） . Vascular injury will lead to complications such as prolonged operative time, intraoperative hemorrhage and ischemia of anastomotic stoma. Superior mesenteric artery （SMA） , superior mesenteric vein （SMV） , gastrointestinal trunk, left colic artery （LCA） , sigmoid artery and marginal vessels in the mesentery have been found with possibility of heteromorphosis, which requires better operative techniques. Surgeons should recognize those vessel heteromorphosis carefully during operations and adjust strategies to avoid intraoperative hemorrhage. Preoperative abdominal computed tomography angiography （CTA） with three-dimensional reconstruction can find vessel heteromorphosis within surgical area before operation. Adequate dissection of veins instead of violent separation will decrease intraoperative bleeding and be helpful for dealing with the potential hemorrhage. When intraoperative hemorrhage occurs, surgeons need to control the bleeding by simple compression or vascular clips depending on the different situations. When the bleeding can not be stopped by laparoscopic operation, surgeons should turn to open surgery without hesitation.