新生儿先天性肠旋转不良相关解剖学标志与腹腔镜手术程序化操作要点

Anatomic landmarks of congenital intestinal malrotation in neonates and key points of programmed surgical procedure during laparoscopy

目的探讨基于新生儿先天性肠旋转不良的相关解剖学标志而制定的程序化手术步骤在腹腔镜Ladd’s手术中的临床应用可行性及效果。方法收集2020年3月至2022年6月经西南医科大学附属医院小儿外科诊治的28例先天性肠旋转不良患儿的临床资料,包括手术年龄、体重、手术时间、术中情况、并发症、术后恢复情况等相关指标。28例患儿中,男17例,女11例。根据先天性肠旋转不良变异的解剖结构(即扭转的中肠、Ladd索带、狭窄并附着不全的系膜根部、变异的肠系膜血管关系),制定腹腔镜Ladd’s手术的程序化手术步骤,即以脾区结肠为参照物复位肠管、松解结肠至结肠中静脉、松解并裸化十二指肠成为腹腔内器官、拓宽肠系膜根部至胰头到阑尾根部的距离>5 cm,并应用于新生儿先天性肠旋转不良的治疗。结果所有患儿均因呕吐入院,患儿病情均平稳,无绞窄性肠梗阻表现,术前均行消化道造影证实为十二指肠梗阻。手术时中位年龄5 d,范围在2~27 d;手术时体重为(2971.43±366.70)g,术中扭转度数360°~720°,复位时间为(10.21±4.12)min。有2例合并环状胰腺同期行十二指肠侧侧吻合,无损伤系膜血管、无中转开腹病例,手术时间为(91.79±18.92)min,术后恢复全肠内营养时间(10.18±1.90)d,随访5~27个月,无复发及肠梗阻病例。结论基于解剖标志的程序化腹腔镜Ladd’s术治疗新生儿先天性肠旋转不良手术效果良好,掌握相关操作要点后可提高手术安全性,减少副损伤,术后恢复快。

Objective To explore the clinical feasibility and outcomes of programmed surgical procedures based upon abnormal anatomic landmarks of congenital intestinal malrotation during laparoscopic Ladd's surgery.Methods From March 2020 to June 2022,the relevant clinical data were retrospectively reviewed for 28 neonates hospitalized for vomiting.There were 17 boys and 11 girls.Operative age,body weight,operative duration,intraoperative findings,complications and postoperative recovery were recorded.According to variant anatomical structures of intestinal malrotation,including twisted midgut,Ladd cord,mesenteric root with narrow/incomplete attachment and variable mesenteric vessels,midgut was rearranged by left transverse colon,releasing colon until middle colonic vein,liberating duodenum until it became an intra-abdominal organ and widening mesenteric root until the distance from pancreatic head to appendix root was more than 5 cm.Results A definite diagnosis of duodenal obstruction was made by upper gastrointestinal contrast.All of them remained stable without strangulation obstruction.The median operative age was 5(2-27)days and average weight(2971.43±366.70)gram.Midgut volvulus was(360-720)degree and average reset time(10.21±4.12)min.Two cases underwent side-to-side duodenal anastomosis due to annular pancreas.There was no mesenteric vascular injury or conversion into laparotomy.Average operative duration was(91.79±18.92)min and average total enteral nutrition support time(10.18±1.90)days intraoperatively.There was no recurrence or intestinal obstruction during a follow-up period of(5-27)month.Conclusions Based upon anatomic landmarks,programmed laparoscopic Ladd's surgery is both methodical and smooth for neonatal congenital intestinal malrotation.It may boost the safety of surgery and minimize collateral injuries after grasping key points.There are also the advantages of fast recovery.