腹膜外脾切除——困难腹腔镜脾切除的新入路

Extraperitoneal Splenectomy:a New Approach of Complex Laparoscopic Splenectomy

目的探讨腹腔镜腹膜外脾切除这一新的手术入路的安全性和可行性。方法2017年5月~2019年11月我们采用腹膜外入路完成困难腹腔镜脾切除术(laparoscopic splenectomy,LS)17例,超声刀切开Gerota筋膜,将其掀起,在腹膜后方游离(可以有效避免出血),游离至脾蒂下极胰尾下方用超声刀切开Gerota筋膜及腹膜,建立脾蒂下方隧道,离断脾蒂,将脾脏切除。结果17例均顺利完成LS,无中转开腹。手术时间(179.1±53.0)min,术中出血量(77.7±30.5)ml。术后住院时间(12.4±10.0)d。术后发生低蛋白、腹水2例,迟发性腹腔出血、腹腔感染1例,肺感染2例,并发症发生率29.4%(5/17)。术后病理:慢性淤血性脾肿大12例,脾囊肿伴血管扩张3例,脾海绵状血管瘤2例。17例术后随访1~3年,无死亡病例。结论腹腔镜腹膜外脾切除是一种安全可行的手术入路,能够有效避免术中大出血及中转开腹的发生,保证困难LS的安全进行。

Objective To investigate the safety and feasibility of a new approach of extraperitoneal laparoscopic splenectomy.Methods A total of 17 patients receiving complex laparoscopic splenectomy from May 2017 to November 2019 were retrospectively analyzed.The Gerota fascia and peritoneum were cut by ultrasonic scalpel to lift it for separation behind the peritoneum(which can effectively avoid bleeding).When the Gerota fascia and peritoneum were dissociated to the lower pole of the spleen pedicle and below the tail of the pancreas,a tunnel under the spleen pedicle was established.Then the spleen pedicle was cut off and the spleen was removed.Results All the 17 operations were successfully completed.There was no conversion to laparotomy.The operation time was(179.1±53.0)min,intraoperative blood loss was(77.7±30.5)ml,and postoperative hospital stays was(12.4±10.0)d.Postoperative low-protein ascites occurred in 2 cases,delayed abdominal hemorrhage and infection in 1 case,and pulmonary infection in 2 cases.The incidence of complications was 29.4%(5/17).Postoperative pathology showed 12 cases of chronic congestive splenomegaly,3 cases of splenic cyst with vasodilation,and 2 cases of splenic cavernous hemangioma.Postoperative follow-up time was 1-3 years,and there was no death case.Conclusions Extraperitoneal laparoscopic splenectomy is safe and feasible.It can avoid massive intraoperative blood loss,avoid conversion to laparotomy,and make sure complex laparoscopic splenectomy performed smoothly.