基于手术视频儿童等离子扁桃体术后迟发性出血的病因分析

Analysis of the causes of postoperative delayed hemorrhage after coblation assisted tonsillectomy in children based on surgery video

目的通过保存的扁桃体术中手术视频资料,分析儿童等离子扁桃体术后迟发性出血的原因并减少出血率。方法回顾性分析2019年1~12月华中科技大学同济医学院附属武汉儿童医院耳鼻咽喉科行等离子扁桃体切除术患儿1116例,迟发性出血15例,通过患儿病历和术中手术视频资料,分析儿童扁桃体切除术后迟发性出血的病因。结果8例术中手术视频资料和出血点无明显关系,感染因素4例,术后进食不当3例,原因不明1例;2例可能与三角皱襞淋巴滤泡切除及有咽喉反流症状有关;5例慢性扁桃体炎黏连切除后与术中操作有相关性,弥漫止血2例,扁桃体背膜处裸露小血管2例,突入扁桃体背膜肌层1例。结论对于慢性扁桃体炎粘连明显的不建议过多使用等离子止血,可考虑前后弓带肌层缝合;背膜处裸露小血管建议追踪血管走形,彻底止血;局部突入肌层处仍建议带肌层缝合。术前评估患儿是否有咽喉反流症状,术中减少下极三角皱襞及淋巴滤泡切除,术后预防性使用抑酸治疗且睡前2 h禁饮食。

OBJECTIVE To analyze the causes of delayed hemorrhage after tonsillectomy in children through the saved surgery video during operation and reduce the probability of delayed hemorrhage after tonsillectomy.METHODS The clinical data of 15 cases with delayed hemorrhage out of 1116 children after tonsillectomy between January 2019 and December 2019 in the Department of Otolaryngology,Wuhan Children's Hospital,Tongji Medical College,Huazhong University of Science&Technology were retrospectively analyzed.Medical history and intraoperative surgery video were used to analyze the causes of delayed hemorrhage after coblation assisted tonsillectomy in children.RESULTS There was no obvious relationship between intraoperative surgery and postoperative bleeding in 8 cases(4 cases with infectious factors,3 cases with improper eating after operation,1 case with unknown cause).And 2 cases were possibly related to the removal of the deltoid fold lymphoid follicles and laryngopharyngeal reflux.Five cases with chronic tonsillitis were related to intraoperative procedures(2 cases of diffuse hemostasis,2 cases of exposed small blood vessels at the dorsal membrane of the tonsils,1 case of protruding into the dorsal membrane of the tonsils).CONCLUSION For chronic tonsillitis with obvious adhesions,too use of coblation is not recommended for hemostasis,but anterior and posterior arch muscle layer sutures can be considered;For the exposed small blood vessels at the posterior membrane of the tonsil,it is recommended to track the shape of the blood vessel and to stop bleeding completely;And for blood vessel local protruding into the muscle layer,it is still recommended to suture the muscle layer.To evaluate the children's laryngopharyngeal reflux symptom before surgery and use acid suppression therapy after surgery,not remove the inferior delta folds and lymphoid follicle too much during the surgery,and abstain from eating and drinking 2 hours before bedtime can prevent delayed hemorrhage after coblation assisted tonsillectomy in children.