腹腔镜技术在急性肠系膜血管缺血性疾病诊断中的应用

Application of Laparoscopy in the Diagnosis for Acute Mesenteric Ischemia

目的探讨腹腔镜技术在急性肠系膜血管缺血性疾病(acute mesenteric ischemia,AMI)诊断中的应用价值。方法回顾性分析我院2006年8月～2018年1月11例术前检查不能明确的可疑AMI患者资料,均行腹腔镜探查。结果8例(72. 7%)术中证实为急性肠缺血坏死,均中转开腹手术切除坏死段肠管,其中7例行Ⅰ期吻合,1例因缺血坏死肠管广泛,结肠内容物较多,腹腔污染严重而行远段小肠造瘘术,术后2天因腹痛剧烈不缓解再次行腹腔镜探查,发现部分残余小肠肠管呈渐进性缺血坏死,再次行坏死小肠切除+小肠造瘘术,平均手术时间110 min(78～185 min),平均出血量95 ml (40～210 ml),平均住院时间11 d(7～28 d),8例均痊愈出院,术后均于门诊定期复诊6个月,未再次出现明显腹痛、腹胀等症状,进食正常,大便良好,其中二次手术者术后3个月行小肠造瘘还纳,术后恢复良好。另3例探查术中见肠管远端存在不同程度粘连,血运、蠕动正常,无明显出血、坏死表现,行肠粘连松解术。结论对于腹部症状和体征不相符,伴有急性肠梗阻的可疑AMI患者,在严格掌握探查指征以及手术时机情况下,腹腔镜技术可有效地用于AMI的诊断。

Objective To investigate clinical value of laparoscopy in the early diagnosis of acute mesenteric ischemia ( AMI).Methods A total of 11 cases with suspected AMI who were not definitively diagnosed by preoperative workup in our hospital from August 2006 to January 2018 were reviewed.They underwent laparoscopic exploration.Their clinical data were analyzed retrospectively.Results Among the 11 patients who underwent laparoscopic exploration because of unclear preoperative diagnosis, 8 (72.7%) were definitely diagnosed and proved to be acute intestinal ischemic necrosis during operation.All of them were converted to open surgery to resect necrotic intestinal canal, including 7 cases of stage Ⅰ anastomosis and 1 case of distal enterostomy because of extensive ischemic necrosis of intestinal canal, large amount of colonic contents and severe peritoneal contamination.Because of severe abdominal pain without relief, a laparoscopic re-exploration was performed on the second day after the first operation.It was found that part of the residual small intestine showed progressive ischemic necrosis.Necrotized small intestine resection and enterostomy were performed once again.The mean operation time was 110 minutes ( range, 78 - 185 minutes);the mean bleeding volume was 95 ml ( range, 40 - 210 m1);the mean hospitalization time was 11 days ( range, 7 - 28 days).All the 8 cases with AMI were cured and discharged from hospital.The follow-ups lasted for 6 months.No obvious abdominal pain or distension occurred again.The patients had good appetite and normal stool.The case with laparoscopic second operation underwent return of enterostomy 3 months later and recovered well.In another 3 cases, the distal intestinal tract with adhesion was found to have normal blood supply and peristalsis, without obvious hemorrhage or necrosis, and intestinal adhesiolysis was performed.Conclusions Suspicious AMI patients with inconsistent abdominal symptoms and signs are often accompanied by acute intestinal obstruction.Laparoscopic exploration can be effectively applied for the diagnosis of AMI under strict surgical indications and proper operative opportunity.