李國(guó)鋒　謝永燦

1)廣東羅定市中醫(yī)院普外科　羅定　527200　2)廣東羅定市人民醫(yī)院普外科　羅定　527200

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腹腔鏡下門奇靜脈斷流加脾切除術(shù)效果觀察

李國(guó)鋒1)謝永燦2)

1)廣東羅定市中醫(yī)院普外科羅定5272002)廣東羅定市人民醫(yī)院普外科羅定527200

目的探討腹腔鏡下脾切除+門奇靜脈斷流術(shù)治療肝硬化門靜脈高壓癥的效果。方法選取65例2013-06-2015-06間收治的肝硬化門靜脈高壓癥患者，根據(jù)手術(shù)方式的不同分為2組。腔鏡組36例采用腹腔鏡下門奇靜脈斷流術(shù)+脾切除術(shù)，開腹組29例采用傳統(tǒng)開腹手術(shù)。比較2組治療效果。結(jié)果65例均成功手術(shù)。腔鏡組手術(shù)時(shí)間長(zhǎng)于開腹組，術(shù)中出血量、術(shù)后下床時(shí)間、平均排氣時(shí)間、住院時(shí)間及術(shù)后并發(fā)癥發(fā)生率均少于或短于對(duì)照組，差異均有統(tǒng)計(jì)學(xué)意義(P<0.05)。結(jié)論腹腔鏡下門奇靜脈斷流術(shù)+脾切除治療肝硬化門靜脈高壓癥，近期療效優(yōu)于傳統(tǒng)開腹手術(shù)。

門靜脈高壓癥；腹腔鏡；脾切除；門奇靜脈斷流術(shù)

門靜脈高壓食管曲張靜脈破裂出血是患者的主要致死原因。臨床多選用脾切除+門奇靜脈斷流術(shù)治療[1]。2013-06—2015-06，我們選取36例肝硬化門靜脈高壓癥患者，擇期在腹腔鏡下行門奇靜脈斷流術(shù)+脾臟切除，近期效果滿意，現(xiàn)報(bào)道如下。

1　資料與方法

1.1一般資料本組共65例患者，均根據(jù)臨床表現(xiàn)、實(shí)驗(yàn)室檢查和影像學(xué)檢查結(jié)果確診為肝硬化門靜脈高壓癥。根據(jù)手術(shù)方式不同將患者分為2組。腔鏡組36例中男27例，女9例；年齡30～70歲，平均55.40歲。脾臟：(269×106×52)mm。肝功能A級(jí)25例，B級(jí)11例[2]。乙肝32例、血吸蟲1例，酒精2例，其他1例。開腹組29例中男21例，女8例；年齡33～59歲，平均50.12歲。脾臟：(254×97×61)mm。肝功能A級(jí)23例、B級(jí)6例。乙肝26例，血吸蟲1例，酒精1例，其他1例。2組患者的性別、年齡、肝功能分級(jí)等比較，差異無統(tǒng)計(jì)學(xué)意義(P>0.05)，有可比性。

1.2方法均在氣管插管全身麻醉下施術(shù)。開腹組：入腹。切除脾臟后行賁門周圍血管離斷術(shù)。脾窩置入引流管，關(guān)腹。腔鏡組：(1)取低腿截石位。臍緣切口穿刺建立氣腹，壓力(10～12)mmHg。穿刺10 mm Trocar置入30°腹腔鏡。左鎖骨中線肋緣下、右鎖骨中線肋緣下、劍突下、左鎖骨中線與臍水平線交點(diǎn)上約5 cm處，分別穿刺置入Trocar。以左鎖骨中線肋緣下穿刺12 mm Trocar為切脾的主操作孔，依據(jù)術(shù)中需求更換主操作孔。(2)脾切除：通過超聲刀自脾下極處，依次處理脾胃韌帶、脾結(jié)腸韌帶、脾腎韌帶、脾膈韌帶及脾蒂。碎脾后將其取出。(3)門奇靜脈斷流術(shù)：患者改仰臥位，分離胃結(jié)腸韌帶后，提起胃大彎，從下方解剖出胃左動(dòng)、靜脈，夾閉后離斷。緊貼胃壁向小彎側(cè)近端逐步依次離斷食管前后兩側(cè)的迷走神經(jīng)，繼續(xù)游離食管下段6～8 cm，離斷注入食管下段和賁門周圍的所有血管。

1.3觀察指標(biāo)觀察2組手術(shù)時(shí)間、術(shù)中出血量、術(shù)后下床時(shí)間、排氣時(shí)間、并發(fā)癥及住院時(shí)間等[3]。

2　結(jié)果

2.12組患者近期效果情況對(duì)比65例手術(shù)均獲成功。腔鏡組手術(shù)時(shí)間長(zhǎng)于開腹組，術(shù)中出血量、術(shù)后下床時(shí)間、排氣時(shí)間及住院時(shí)間均明顯優(yōu)于開腹組，差異均有統(tǒng)計(jì)學(xué)意義(P<0.05)，見表1。

表1　2組患者近期效果比較±s)

2.22組術(shù)后并發(fā)癥情況對(duì)比腔鏡組術(shù)后并發(fā)癥發(fā)生率8.3%，明顯低于開腹組的48.2%，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)，見表2。

表2　2組并發(fā)癥比較[n(%)]

3　討論

我們對(duì)門靜脈高壓患者實(shí)施腹腔鏡下門奇靜脈斷流+脾切除術(shù)，并與開腹手術(shù)進(jìn)行比較，結(jié)果顯示，腹腔鏡手術(shù)安全性高、近期療效確切。但手術(shù)需嚴(yán)格掌握適應(yīng)證[4]：(1)脾臟周圍無明顯炎癥粘連。(2)無凝血功能障礙。(3)排除Child C級(jí)、不耐受者及心肺疾病患者。腹腔鏡下門奇靜脈斷流術(shù)中較常見的并發(fā)癥為術(shù)中出血，這也是中途轉(zhuǎn)開腹手術(shù)的主要原因。故手術(shù)成功的關(guān)鍵是避免術(shù)中出血。因此術(shù)中分離胃短血管時(shí)采用LigaSure新型超聲刀，解剖時(shí)動(dòng)作小心輕柔，多以鈍頭為主[5]。腹腔鏡下門奇靜脈斷流手術(shù)中將賁門周圍血管給予徹底離斷，尤其是高位食管支與左膈下靜脈，這是開腹手術(shù)所不具備的。沿著賁門右側(cè)食管下段右后方上行，盡量分離至賁門上6～8 cm或更高部位，以避免或減少高位食管支的遺漏[6]，提高手術(shù)成功率。

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(收稿2016-03-04)

Clinical effect of laparoscopic portal azygous vein disconnection combined with splenectomy and conventional operation

LiGuofeng1)XieYongcan2)

1)Departmentofgeneralsurgery,LuodingHospitalofTraditionalChineseMedicine,Guangdong,527200,China. 2)Departmentofgeneralsurgery,LuodingPeople'sHospital,Guangdong,527200,China

ObjectiveTo study the clinical effect of laparoscopic splenectomy combined with portal azygous vein disconnection and conventional laparotomy in the treatment of portal hypertension. MethodsTotally 65 patients with portal hypertension treated from June 2013 to June 2015 in our hospital were selected. The patients were divided into two groups according to different operation methods, 36 cases in each group. The observation group adopted laparoscopic portal azygous vein disconnection combined with splenectomy; the control group adopted the conventional laparotomy. The clinical effect for two groups was observed. ResultsThe operation was successful. The average operation time for observation group was longer than that of control group. The intraoperative bleeding amount, time of leaving bed, average evacuation time and hospital stays of observation group was better than that of control group. The incidence rate of complications (7.7%) of observation group was lower than that of control group (46.2%) (P<0.05). ConclusionLaparoscopic portal azygous devascularization operation + spleen resection for the treatment of liver cirrhosis and portal hypertension recently and the curative effect is better than traditional open surgery and is worthy of clinical application.

Cirrhosis; Portal Hypertension; Laparoscopic; Splenectomy + Portal Azygous Vein Disconnection; Clinical Effect

R657.3+4

B

1077-8991(2016)05-0005-02