全腹腔镜下二级脾蒂离断法原位巨脾切除术的临床研究

Complete laparoscopic splenectomy by two steps of spleen subpedicle transection for massive splenomegaly

目的总结全腹腔镜下二级脾蒂离断法原位巨脾切除术的手术要点和临床体会。方法回顾性分析2013年1月~2017年6月48例实施巨脾切除术的患者临床资料,根据手术方式分为观察组(全腹腔镜下二级脾蒂离断法原位巨脾切除)和开放组(开腹传统法)。比较2组患者手术时间、术中出血、留置腹腔引流管情况、术后拔除引流管时间、并发症及术后住院时间等指标。结果48例患者均成功完成手术,其中观察组25例均成功在全腹腔镜下完成二级脾蒂离断法原位脾切除术,无中转开腹,观察组手术时间比开放组长(130.40±63.60 min vs 99.13±33.97 min,P=0.038),术中出血量更少(75.20±50.67 mL vs 206.09±116.77 mL,P=0.000),术后住院时间更短(8.24±2.20天vs 11.00±3.49天,P=0.002);观察组留置腹腔引流管的例数更少,差异有统计学意义(P<0.05),但两组术后拔除引流管的时间相当;两组间脾窝积液、切口感染和发热两组差异无统计学意义(P>0.05);而观察组术后胸腔积液少于开放组,其差异有统计学意义(P<0.05));两组均无腹腔出血,腹腔感染,门静脉系统血栓,胰瘘,胃瘘,肝功能衰竭等并发症。术后随访6个月,患者无门静脉系统血栓及肝功能衰竭并发症,胸腔积液已吸收。结论全腹腔镜下二级脾蒂离断法原位巨脾切除安全可靠,与开腹传统方法比较,术中出血更少,恢复更快。

Objective To discuss the key points and safety of two steps of splenic pedicle transection in complete laparoscopic in situ splenectomy for massive splenomegaly.Methods A retrospective analysis was conducted on the clinical data of 48 patients with massive splenomegaly receiving splenectomy from January 2013 and June 2017.According to the operation method the patients were divided into observation group(two steps of splenic pedicle transection in complete laparoscopic in situ splenectomy)and the open group(traditional open splenectomy).Results Forty-eight patients were successfully completed surgery,and 25 patients in study group were successfully completed two steps of splenic pedicle transection in complete laparoscopic in situ splenectomy,no transfer to open surgery.The average opera-tion in observation group was longer than that in open group(130.40±63.60 min vs 99.13±33.97 min),while the intraoperative blood loss(75.20±50.67 mL vs 206.09±116.77 mL)were less and postoperative hospital stay(8.24±2.20 d vs 11.00±3.49 d)were shorter(P<0.05).The number of cases of abdominal cavity drainage tube was less inobservation group(P<0.05),but the time of wipe out the abdominal cavity drainage in the both groups was almost the same.There were no significant differences in splenic fossa effusion,incision infection and fever between the two groups(P>0.05).In observation group,the postop-erative pleural effusion was better than that in the open group,and the difference was statistically signifi-cant(P<0.05).No complications such as abdominal bleeding,abdominal infection,portal venous throm-bosis,pancreatic fistula,gastric fistula,liver failure were found in both groups.The patients were followed up for 6 months after the operation.There were no complications of portal venous thrombosis and liver failure,and pleural effusion was absorbed.Conclusion Two steps of splenic pedicle transection in complete laparoscopic in situ splenectomy for massive splenomegaly is safe and reliable,and compared with traditional laparotomy method,less intraoperative bleeding,faster recovery.