CAJ | 학술논문

目的探讨腹腔镜手术大血管损伤的原因及处理对策.方法回顾2006年3月至2011年2月1858例行腹腔镜手术患者的临床资料,术中发生大血管损伤10例,男6例,女4例.年龄21 ～78岁,平均49岁.其中主动脉损伤2例,腔静脉损伤2例,肾静脉损伤4例,骼外静脉损伤1例,骼外动脉损伤1例.血管损伤原因包括:解剖认识不足造成损伤2例,建立第1个穿刺孔时损伤1例,术中用力过猛致损伤2例,解剖变异致损伤2例,手术粘连分离困难致损伤3例.处理方法:保持气腹压力,短时间出血量较大时可迅速增加至20 mm Hg(1 mm Hg=0.133 kPa),用吸引器吸尽创面出血,仔细辨认出血部位,必要时增加穿刺孔,让助手协助暴露.若为静脉破裂出血可用4-0无损伤血管缝线根据破口大小行8字或连续缝合血管破口.若为动脉破裂出血,先用动脉血管钳夹闭血管破口上下两端,控制出血,然后同静脉破裂出血方式缝合破口.结果 10例患者7例腹腔镜下止血成功,3例中转开放手术止血.7例腹腔镜下止血成功者修补血管时间8～ 25 min,平均14 min;术中出血150 ～1600 ml,平均530 ml.破口大小0.2～1.0cm.1例主动脉损伤术后局部有较大血肿,术后3个月复查血肿完全吸收,余9例术后无气栓、继发出血等并发症.结论腹腔镜手术大血管损伤由多种原因引起,良好的心态和精细的缝合是止血的关键,术中助手良好的配合也起着重要作用.
목적 탐토복강경수술대혈관손상적원인급처리대책.방법 회고2006년3월지2011년2월1858례행복강경수술환자적림상자료,술중발생대혈관손상10례,남6례,녀4례.년령21 ～78세,평균49세.기중주동맥손상2례,강정맥손상2례,신정맥손상4례,격외정맥손상1례,격외동맥손상1례.혈관손상원인포괄:해부인식불족조성손상2례,건립제1개천자공시손상1례,술중용력과맹치손상2례,해부변이치손상2례,수술점련분리곤난치손상3례.처리방법:보지기복압력,단시간출혈량교대시가신속증가지20 mm Hg(1 mm Hg=0.133 kPa),용흡인기흡진창면출혈,자세변인출혈부위,필요시증가천자공,양조수협조폭로.약위정맥파렬출혈가용4-0무손상혈관봉선근거파구대소행8자혹련속봉합혈관파구.약위동맥파렬출혈,선용동맥혈관겸협폐혈관파구상하량단,공제출혈,연후동정맥파렬출혈방식봉합파구.결과 10례환자7례복강경하지혈성공,3례중전개방수술지혈.7례복강경하지혈성공자수보혈관시간8～ 25 min,평균14 min;술중출혈150 ～1600 ml,평균530 ml.파구대소0.2～1.0cm.1례주동맥손상술후국부유교대혈종,술후3개월복사혈종완전흡수,여9례술후무기전、계발출혈등병발증.결론 복강경수술대혈관손상유다충원인인기,량호적심태화정세적봉합시지혈적관건,술중조수량호적배합야기착중요작용.
Objective To summarize the causes and treatment strategies for laparoscopic vascular injuries.Methods We had retrospectively reviewed 1858 cases of laparoscopic surgeries from March 2006 to February 2011.There were 10 cases (6 males and 4 females) had intraoperative vascular injuries.The mean age of these 10 patients was 49 years (ranged from 21 to 78 years).2 cases were aortic injuries,2 cases were vena cava injuries,4 cases were renal vein injuries,1 case was iliac vein injury and 1 case was iliac artery injury.The causes of vascular injuries included 2 cases caused by lack of anatomical understanding; 1 cases occurred during establishment of the first puncture site ; 2 cases caused by forced operation during the procedure; 2 cases caused due to ectopic anatomy; 3 cases caused due to adhesions and difficulties in dissection.Treatment strategies were maintaining pneumoperitoneum pressure and rapidly increasing the pressure to 2.6Kpa if a large amount of bleeding in a short time.With the help of suction,the bleeding sites could be identified.If necessary,an additional trocar was added to help exposure.The bleeding was closed with 4-0 vessel sutures.For arterial bleeding,the upper and lower ends of blood vessel ruptures were clipped with bulldog clamp,then follow the same procedures of variceal bleeding sutures if the bleeding were controlled.Results In 7 of the 10 cases,the bleedings were successfully controlled by laparoscopic technique,while the other 3 were converted to open surgery for bleeding control.The average laparoscopic hemostasis time in the 7 cases was 14 min (range from 8 to 25 min),the average blood loss was 530 ml (range from 150 to 1600 ml).Rupture size were 0.2-1.0 cm.One aortic injury case had complication of big post operative local hematoma which was spontaneously absorbed 3 months after surgery.And the other 9 patients did not have air embolism,hemorrhage and other complications.Conclusions Laparoscopic vascular injuries can be caused by a variety of causes.The strategies of controlling the bleeding are calmness and the fine suturing to control bleeding.A skillful assistant also plays an important role in dealing with this complication.