经胰尾上缘后间隙入路二级脾蒂分离技术在腹腔镜脾部分切除术中的应用价值

Application value of secondary splenic pedicle separation technology through superior posterior approach of the pancreatic tail in laparoscopic partial splenectomy

目的：探讨经胰尾上缘后间隙入路二级脾蒂分离技术在腹腔镜脾部分切除术中的应用价值。方法：采用回顾性横断面研究方法。收集2016年3月至2017年10月浙江省宁波市第一医院收治的13例行腹腔镜部分脾切除术患者的临床病理资料。患者术前均经CT血管造影检查评估后，经胰尾上缘后间隙入路，采用二级脾蒂分离技术施行腹腔镜脾部分切除术。观察指标：（1）术中及术后恢复情况。（2）随访情况。采用门诊方式进行随访，随访内容为术后4周外周血血小板（PLT）变化、脾静脉栓塞、病变残留及复发情况。随访时间截至2017年11月。计量资料以平均数（范围）表示。结果：（1）术中及术后恢复情况：13例患者均成功采用经胰尾上缘后间隙入路二级脾蒂分离技术施行腹腔镜部分脾切除术，无中转开腹，其中6例行腹腔镜脾下极部分切除术，7例行腹腔镜脾上极部分切除术。13例患者手术时间为42-93 min，平均手术时间为61 min；术中出血量为30-260 mL，平均术中出血量为92 mL；术后胃肠功能恢复时间为22-47 h，平均术后胃肠功能恢复时间为34 h；术后引流管拔除时间为3.0-6.0 d，平均术后引流管拔除时间为4.2 d。13例患者术后病理学检查结果：脾囊肿7例、脾血管瘤2例、脉管瘤2例、脾错构瘤1例、脾淋巴管瘤1例。13例患者中，1例术后5 d脾窝积液、发热，B超检查引导下行穿刺置管引流术后好转。13例患者术后住院时间为7.0-16.0 d，平均术后住院时间为9.6 d。（2）随访情况：13例患者术后均获得随访，随访时间为1.0-19.5个月，中位随访时间为8.5个月。随访期间，13例患者外周血PLT正常；脾静脉彩色多普勒超声检查未发现静脉栓塞，CT血管造影检查示血管灌注良好；7例脾囊肿无复发，6例脾肿瘤无肿瘤残留及复发。结论：采用经胰尾上缘后间隙入路二级脾蒂分离技术行腹腔镜脾切除术安全有效，能够精准解剖脾门，保护残留脾脏血供及功能，减少手术副损伤。

Objective：To investigate the application value of secondary splenic pedicle separation technology through superior posterior approach of the pancreatic tail in laparoscopic partial splenectomy. Methods： The retrospective cross-sectional study was conducted. The clinicopathological data of 13 patients who underwent laparoscopic partial splenectomy in the Ningbo First Hospital from March 2016 to October 2017 were collected. After preoperative assessment using computed tomography（CT） angiography, 13 patients underwent laparoscopic partial splenectomy using secondary splenic pedicle separation technology through superior posterior approach of the pancreatic tail. Observation indicators： （1） intra- and post-operative recovery situations; （2） follow-up situations. Follow-up using outpatient examination was performed to detect postoperative changes of peripheral blood platelet （PLT）, thrombosis of splenic vein, lesions residual or recurrence up to November 2017. Measurement data were represented as average （range）.Results：（1） Intra- and post-operative recovery situations： 13 patients underwent successful laparoscopic partial splenectomy using secondary splenic pedicle separation technology through superior posterior approach of the pancreatic tail, without conversion to open surgery, including 6 with laparoscopic partial splenectomy of inferior pole of the spleen and 7 with laparoscopic partial splenectomy of upper pole of the spleen. Operation time was 42-93 minutes, with an average of 61 minutes; volume of intraoperative blood loss was 30-260 mL, with an average of 92 mL; postoperative gastrointestinal function recovery time was 22-47 hours, with an average of 34 hours; postoperative drainage tube removal time was 3.0-6.0 days, with an average of 4.2 days. The postoperative pathological examination of 13 patients： 7, 2, 2, 1 and 1 patients were respectively confirmed with splenic cysts, splenic hemangiomas, vascular hemangiomas, splenic hamartoma and splenic lymphangioma. Of 13 patients, 1 was complicated with splenic recess effusion and fever, and was improved with B ultrasound-guided percutaneous catheter drainage. Duration of hospital stay of 13 patients was 7.0-16.0 days, with an average of 9.6 days. （2） Follow-up situations： 13 patients were followed up for 1.0-19.5 months, with a median time of 8.5 months. During the follow-up, PLT level of 13 patients was normal. Color Doppler ultrasound examination showed no venous embolism, and CT angiography showed good vascular perfusion. There was no recurrence of splenic cysts in 7 patients and no tumor residual or recurrence in 6 patients. Conclusions：Laparoscopic partial splenectomy using secondary splenic pedicle separation technology through superior posterior approach of the pancreatic tail is safe and effective, and it can precisely dissect splenic hilum, preserve blood supply and function of the remnant spleen, and reduce surgical injury.