腹腔镜手术第一穿刺方法的探讨

Study on safety of first puncture in laparoscopic surgey

目的 :介绍一种改良的开放式第一穿刺方法 ,并对几种腹腔镜手术第一穿刺方法的安全性进行探讨。 方法 :4 10 2例腹腔镜手术采用 4种第一穿刺方法进入腹腔 :A组 2 4 92例 ,气腹形成后进行套管针穿刺 ;B组 798例 ,切开脐孔皮肤 ,套管针直接穿刺 ;C组 387例 ,切开脐孔皮肤、皮下脂肪及筋膜 ,套管针直接穿刺 ;D组 4 2 5例 ,用改良的开放式第一穿刺方法 ,即切开脐孔 ,套管鞘直接插入腹腔。一次穿刺 3次以上未进入腹腔或进入腹腔为成功 ;气腹针或套管穿刺针穿刺两次为穿刺不安全、不顺利 ;穿刺 3次以上未进入腹腔或进入皮下或引起血管或器官损伤为失败。 结果 :A组与B组的穿刺成功率无统计学差异(P >0 .0 5 ) ,C组和D组穿刺成功率明显高于A组 (P <0 .0 1) ,D组穿刺成功率显著高于C组 (P <0 .0 1) ,且无不顺利及失败。38位初学者用 4种方法穿刺 6 33例 ,统计学分析结果相似。各组均无血管、器官损伤并发症。 结论 :采用切开脐孔筋膜直接套管针穿刺或切开脐孔套管鞘直接插入腹腔成功率高 ,特别在进行初学者培训中 ,更为安全。

Objective: To introduce an improved direct method for first puncture and to study the safety of first puncture in laparoscopic surgery.Methods: Four kinds of techniques were used to perform the first puncture on 4 102 patients.Group A: trocar puncture were performed after pneumoperitoneum in 2 492 cases.Group B: trocar puncture was directly through the incision of umbilical skin in 798 patients; Group C: trocar puncture was directly through the incision of umbilic skin,subcutancous fat and fascia in 387 patients.Group D: opened umbilical hole and inserted the trocar shell without puncture in 425 cases.it was a success if entered the abdominal cavity at the first time,it was unsafe if punctured twice and a failure if the needle hadn't entered the abdominal cavity for 3 times or went into the subcutaneous vessels or viscera.Results: There were no vessels and viscera injury during punctures in our study.The puncture results were related to the different methods.Compared with group A, the success rate of group C and D were significantly improved( P <0.01).Group B was similar to that of group A( P >0.05).Success rates of group C and D were significantly higher than that of group A.The success rate was higher in group D than in group C( P <0.01).For 633 cases who received puncture by 38 learners,the results of punctrue were similar.There was no unsafety and failure case in group D.Conclusion: Direct trocar puncture after incision of umblical hole is safer and easier to perform than routine method.Trocar shell insertion is better than other methods especially for learning doctors.