全腹腔镜手术治疗脾亢门静脉高压症(附12例报告)

Totally laparoscopic surgery for hypersplenism and portal hypertension:with a report of 12 cases

目的:探讨全腹腔镜手术治疗脾亢门静脉高压症的应用价值。方法:回顾分析2011年5月至2021年4月为12例门静脉高压症患者施行完全腹腔镜脾切除及断流术的临床资料,记录手术时间、手术出血量、术后并发症、术后恢复情况。结果:10例手术顺利完成,2例中转开腹。1例术中行贲门周围血管离断术造成膈肌损伤,行腹腔镜膈肌修补及胸腔闭式引流术。手术时间120~280 min,平均(215.0±52.1)min,其中切脾时间80~130 min,平均(107.0±16.4)min;断流时间40~90 min,平均(63.8±18.5)min;取脾时间30~80 min,平均(54.0±14.3)min。术中出血量50~1000 mL,平均(400.0±245.9)mL。术前患者均放置胃管,于术后24 h内拔除。术后2~4 d拔除引流管。术后住院4~12 d,平均(9.8±2.1)d。术后发热(T>38.5℃)2例,对症处理后体温恢复正常。12例术后血小板均升高,1周左右达峰值,均口服硫酸氢氯吡格雷片,血小板恢复至正常水平。1例于术后1周超声检查发现门静脉血栓形成,服用硫酸氢氯吡格雷片1个月后恢复正常。术后随访,均无呕血、黑便等消化道出血症状。结论:全腹腔镜手术治疗脾亢门静脉高压症安全、可行,术者需具备一定的腹腔镜操作经验及丰富的手术技巧,熟练使用手术器械,注意术中出血的处理及脾蒂、贲门周围血管神经的解剖。

Objective:To investigate the application value of totally laparoscopic surgery in the treatment of hypersplenism and portal hypertension.Methods:The clinical data of 12 patients with portal hypertension who underwent totally laparoscopic splenectomy and devascularization from May 2011 to Apr.2021 were retrospectively analyzed,including operation time,intraoperative bleeding,postoperative complications and postoperative recovery.Results:Ten operations were successfully completed,and 2 cases were converted to laparotomy.One case of diaphragm injury caused by pericardial devascularization during operation,and underwent laparoscopic diaphragmatic repair and closed thoracic drainage.The total duration of surgery was 120-280 min,with an average of(215.0±52.1)min.The splenectomy time was 80-130 min,with an average of(107.0±16.4)min.The devascularization time was 40-90 min,with an average of(63.8±18.5)min.The spleen acquisition time was 30-80 min,with an average of(54.0±14.3)min.The intraoperative blood loss was 50-1000 mL,with an average of(400.0±245.9)mL.Gastric tube was placed in all patients before operation and removed within 24 h after operation.The drainage tube was removed 2-4 d after operation.The postoperative hospital stay was 4-12 d,with an average of(9.8±2.1)d.Postoperative fever(T>38.5℃)occurred in 2 cases,and the body temperature returned to normal after symptomatic treatment.Platelet increased in all 12 cases after operation,reaching the peak value about 1 week later.All patients took clopidogrel bisulfate tablets orally,and the platelet returned to normal level.One case of portal vein thrombosis was found by ultrasound 1 week after operation,treated with clopidogrel hydrogen sulfate tablets,and returned to normal 1 month later.No gastrointestinal bleeding symptoms such as hematemesis or melena occurred during the follow-up.Conclusions:Totally laparoscopic surgery for hypersplenism and portal hypertension is safe and feasible.The surgeons should have certain experience in laparoscopic operation and rich surgical skills,skillfully use surgical instruments,pay attention to the management of intraoperative bleeding and the anatomy of splenic pedicle,pericardial blood vessels and nerves.