优化手术流程和手术操作来减少腹腔镜脾切除术术中及术后并发症

Optimize operation process and operation technique to reduce intraoperative and postoperative complications of laparoscopic splenectomy

目的 通过对不同腹腔镜脾切除术流程和操作的对比,总结出有效减少相关并发症的腹腔镜脾切除手术流程及操作方式.方法 回顾性分析2015年9月-2017年12月重庆医科大学附属第二医院收治的行腹腔镜脾切除术的130例患者的临床资料.按照不同的手术流程及操作方式分成6组.手术流程分组：1组为动脉优先组（首先打开胃结肠韧带处理脾动脉,然后游离脾周韧带,最后离断脾蒂）（n=73）;2组为隧道法程序化原位切脾组（按照腹腔镜入路,先处理脾脏下极,离断脾结肠及脾胃韧带;处理脾动脉;然后建立脾蒂隧道,离断脾蒂;最后游离脾周剩余韧带）（n=57）.离断脾蒂方式分组：3组为直线切割闭合器切割闭合脾蒂组（（n=101）;4组为游离二级脾蒂离断法组（n=29）.是否阻断脾静脉分组：5组为未行脾静脉结扎阻断组（（n=95）;6组为行脾静脉结扎阻断组（n=35）.比较各组患者的术中出血量、手术时间、术后并发症发生率情况.计量资料以均数±标准差（（x）±s）表示;组间比较采用￡检验;计数资料以率（％）的形式表示,组间比较采用x2检验或Fisher确切概率法.结果 与1组相比较,2组出血量更少[1组和2组术中出血量分别为（356.0±96.2）、（220.9±57.3） ml,P=0.016],手术时间更短[1组和2组手术时间分别为（156.0±36.6）、（120.9±55.4） min,P=0.038]和术后并发症更少[1组和2组术后并发症发生率分别为9.6％（7/73）、5.3％（3/57）,P=0.035].与4组相比较,3组出血量更少[3组和4组术中出血量分别为（256.0±85.1）、（380.9 ± 107.3） ml,P=0.019],手术时间更短[3组和4组手术时间分别为（131.0±30.9）、（171.9±61.2） min,P=0.024]以及并发症发生更少[3组和4组术后术后并发症发生率分别为6.9％ （7/101）、10.3％ （3/29）,P=0.048].与6组相比较,5组术中出血量更少[5组和6组术中出血量分别为（250.0±56.2）、（320.9±87.3） ml,P=0.012]、手术时间更短[5组和6组手术时间分别为（136.0±36.2）、（180.9±57.3） min,P=0.013],并且术后并发症更少[5组和6组术后并发症发生率分别为6.3％（6/95）、11.4％ （4/35）,P=0.021].结论 隧道法程序化原位切脾和术中直线切割闭合器的应用可以减少出血量,缩短手术时间,降低术后并发症的发生;脾静脉的结扎是不需要的,结扎脾静脉会增加手术时间和出血风险,也增加了术后并发症的发生风险.

Objective Laparoscopic splenectomy has become an effective method to treat the hypersplenism and splenomegaly caused by various diseases.Although laparoscopic technology is very mature at present,laparoscopic splenectomy is still associated with many complications.This study was based on the comparison of different processes and operation techniques of laparoscopic splenectomy,to summarize a more effective operation process and operation technique which can reduce the related complications of laparoscopic splenectomy.Methods The study reviewed the clinical data of 130 patients＇who underwent laparoscopic splenectomy in our department from September 2015 to December 2017.According to different operation mode and operation technique these patients were divided into 6 groups.Operation process groups：group Ⅰ for arterial priority group （open the gastrocolic ligament and expose splenic artery,then dissociate ligament around the spleen,and finally divide from the spleen pedicel） had 73 cases;group 2 with the way of building a tunnel beneath spleen pedicel and dissecting spleen in situ had 57 cases.With regard to the way of breaking spleen pedicel：group 3 using stapler to break spleen＇s pedicel included 101 cases;group 4 using dissecting the secondary spleen pedicel included 29 cases.Whether blocking the splenic vein：group 5 whose splenic vein was not ligated had 95 cases;group 6 whose splenic vein was ligated coverd 35 cases.Analysis and comparison between groups about intraoperative and postoperative complications related to different groups were made.Measurement date were expressed as （-x ± s）,t test was used for comparison between groups.Count data was expressed as rate（%）,and chi-square test was used for comparison between groups.Results Group 2 has less blood loss [group 1：（356.0 ± 96.2） ml versus group 2：（220.9 ± 57.3） ml,P =0.016],shorter operation time [group 1：（156.0 ± 36） min versus group 2：（120.9 ± 55.4） min;P =0.038] and fewer complications [group 1：9.6% （7/73） versus group 2：5.3% （3/57）;P =0.035].When compared with group 4,group 3 have more advantages in the intraoperative blood loss [group 3：（256.0 ± 85.1） ml versus group 4：（380.9 ± 107.3） ml;P=0.019],the operation time [group 3：（131.0±30.9） min versus group 4：（171.9 ±61.2） min;P=0.024],and the postoperative complications [group 3：6.95 % （7/101） versus group 4：10.3 % （3/29）;P =0.048].When compared with group 5,group 6 has more advantages in the intraoperative blood loss [group 5：（250.0 ± 56.2） ml versus group 6：（320.9 ± 87.3） ml;P =0.012],the operation time [group 5：（136.0 ± 36.2） min versus group 6：（180.9 ± 57.3） min;P =0.013],and the postoperative complications [group 5：6.3% （6/95） versus group 6：11.4% （4/35）;P=0.013].Conclusion Both the procedure of tunnel procedure in situ cutting spleen and the application of stapler can reduce the amount of bleeding,shorten the operation time,and reduce the occurrence of postoperative complications.The ligation of the splenic vein is not necessary because it increases the operation time,the risk of bleeding,and the occurrence of postoperative complications.