全胸腔镜手术治疗小儿先天性肺气道畸形

Complete thoracoscopic surgery in the treatment of congenital pulmonary airway malformation in children

目的总结全胸腔镜肺叶(段)切除术治疗小儿先天性肺气道畸形的手术经验及技术难点。方法回顾性分析2017年1月至2019年12月复旦大学附属儿科医院厦门分院38例采用全胸腔镜肺叶(段)切除的小儿先天性肺气道畸形患儿的临床资料、手术录像回顾及随访结果;收集全胸腔镜下28例行肺叶切除术患儿手术时间、术中出血量、术后疼痛(首次下床活动时间)、切口长度、术后肺部并发症等指标,并与2017年1月前的开放手术肺叶切除术21例患儿数据进行比较。结果38例小儿先天性肺气道畸形患儿均在全胸腔镜下顺利完成手术;其中肺叶切除28例,肺段切除6例,肺叶楔形切除4例。术后随访3个月以上,无严重手术并发症出现:2例右下叶切除术患儿术后48 h胸片示右侧膈肌抬高(2~3肋间),术后3个月恢复正常,肺叶楔形切除患儿1例术后1个月复查CT显示病变少许残留。其中胸腔镜肺叶切除术在切口长度[(2.0±0.5)cm]、术后疼痛(首次下床活动时间)[(24.0±2.0)h]、肺部并发症方面(0)与开放手术[(10.0±0.5)cm,(48.0±1.5)h,5例]比较差异有统计学意义(均P<0.05);胸腔镜下肺段切除术手术技术难度高,相比胸腔镜下肺叶切除术手术时间长、出血量多;胸腔镜肺叶切除术中单肺通气与双肺通气手术时间差异有统计学意义[(96.0±6.0)min比(118.0±7.0)min,t=106.501,P<0.001]。结论全胸腔镜肺叶(段)切除术是治疗小儿先天性肺气道畸形的首选术式,具有术野显露清楚,创伤小,术后痛苦小,恢复快,呼吸系统并发症少等优势;术中单肺通气有利于完成手术。

Objective To summarize the experience and technical difficulties of complete thoracoscopic lobectomy(segmental)in the treatment of congenital pulmonary airway malformation in children.Methods The clinical data,surgical videos and follow-up results of 38 children suffering from congenital pulmonary airway malformation and underwent complete thoracoscopic lobectomy in Children′s Hospital of Fudan University Xiamen Branch from January 2017 to December 2019 were retrospectively analyzed.A statistical comparisons of operative time,intraoperative blood loss,postoperative pain(the first time of getting out of bed),incision length and postoperative pulmonary complications were made between 28 children who underwent the total thoracoscopic lobectomy and 21 children who accepted open surgical lobectomy before January 2017 in Children′s Hospital of Fudan University Xiamen Branch.Results Thirty-eight children with congenital pulmonary airway malformation were successfully operated by complete thoracoscopy.There were 28 lobectomies,6 segmental lobectomies and 4 wedge lobectomies.Postoperative follow-up was conducted for more than 3 months,and no serious surgical complications occurred.Chest radiograph of 2 children with the right lower lobectomy at 48 hours after surgery had the elevation of the right diaphragm(2-3 intercostal),and it returned to normal 3 months after surgery.The CT review of 1 child with pulmonary wedge resection 1 month after surgery displayed a little residual lesion.Thoracoscopic lobectomy was significantly different from open surgery in terms of incision length[(2.0±0.5)cm vs.(10.0±0.5)cm],postoperative pain(the first time of getting out of bed)[(24.0±2.0)h vs.(48.0±1.5)h]and pulmonary complications(0 vs.5 cases).The operative time of single lung ventilation was remarkably different from that of double lung ventilation in thoracoscopic lobectomy[(96.0±6.0)min vs.(118.0±7.0)min,t=106.501,P<0.001].Compared with thoracoscopic lobectomy,thoracoscopic pulmonary segmentectomy has a long time and a large amount of blood loss.Conclusions Complete thoracoscopic lobectomy(segmental)is the first choice for the treatment of congenital pulmonary airway malformation in children,with clear operative field,little trauma,less postoperative pain,quick recovery and fewer respiratory complications.Single-lung ventilation is beneficial for surgical completion.