腹腔镜脾切除联合贲门周围血管离断术治疗门静脉高压症的团队协作与技巧

Totally laparoscopic splenectomy plus pericardial devascularization in treatment of portal hypertension:importance of surgical teamwork and technical hints

目的探讨84例完全腹腔镜脾切除联合贲门周围血管离断术的团队协作和手术经验。方法回顾性分析昆明医科大学第二附属医院同一手术组人员自2014年1月至2017年12月行完全腹腔镜脾切除联合贲门周围血管离断术患者的手术资料。结果成功实施完全腹腔镜下脾切除联合贲门周围血管离断术80例,3例患者术中出现不可控出血而改行手助腹腔镜脾切除联合贲门周围血管离断术。1例先行胆囊切除术,因肝硬化较重术中出血约1 500 ml,终止手术,一周后纠正肝功能、凝血后再行腹腔镜下脾切除联合贲门周围离断术。手术时间146.0±33.0(116.0~243.0)min,术中出血214.0±31.0(60.0~600.0)ml,患者术后3个月内定期行凝血功能和门静脉彩色多普勒超声检查,术后发生门静脉血栓4例,根据血小板和血栓情况给予调整抗血小板和抗凝治疗后治愈。围手术期无患者死亡、大出血、消化道瘘及感染。结论良好的团队配合是保证该手术成功的必备条件。术前进行准确的肝功能评估、术中助手的密切配合、合适的手术入路及灵活应用各种腹腔镜器械是成功施行完全腹腔镜下脾切除联合贲门周围血管离断术的保证。

Objective To study the impact of surgical teamwork in totally laparoscopic splenectomy and pericardial devascularization(LSPD)in the treatment of portal hypertension,and advice on technical hints.Methods A retrospective study was conducted on the clinical features of eighty-four patients who underwent totally laparoscopic splenectomy and pericardial devascularization in the Second Affiliated Hospital of Kun Ming Medical University from January,2014 to December,2017.Results Totally laparoscopic procedures were performed successfully in 80 patients.The procedure was converted to hand-assisted laparoscopic splenectomy and pericardial devascularization in 3 patients because of uncontrollable bleeding.One patient who initially underwent laparoscopic cholecystectomy developed an intraoperative blood loss of 1 500 ml.The surgery was terminated and was continued one week later after stabilization of the patient.Of the 80 patients who underwent totally LSPD,the operation time ranged from 116.0 to 243.0(146.0±33.0)min.The intraoperative blood loss ranged from 60.0 to 600.0(214.0±31.0)ml.Routine coagulation function and portal vein color Doppler ultrasound examination carried out within 3 months after surgery detected postoperative portal vein thrombosis in four patients.They responded successfully to antiplatelet and anticoagulant therapy.There were no perioperative deaths,variceal bleeding,gastrointestinal fistula and infection.Conclusions With proper surgical steps and skilled laparoscopic technique carried out by an experienced team of surgeons,totally laparoscopic splenectomy and pericardial devascularization was safe and effective in treating portal hypertension.Strict perioperative management provided a guarantee for the safe operation.