腹腔镜巨脾切除加断流术治疗肝硬化门静脉高压症

目的 探讨腹腔镜下巨脾切除加断流术治疗肝硬化门静脉高压症(门脉高压)的可行性.方法 回顾分析2003年10月至2010年1月12例行腹腔镜巨脾切除加断流术患者的临床资料.结果 8例完全腹腔镜手术成功,4例中转开腹.12例患者手术时间190～470 min,平均350 min,术中出血200～2200 ml,平均1300ml.8例成功腹腔镜手术时间190～410 min,平均313 min,术中出血200～1700ml,平均700ml,术后排气时间3～5 d,术后10～20 d出院.结论 腹腔镜下巨脾切除加断流术治疗肝硬化门脉高压在条件充分的情况下是可行的,可作为肝硬化门脉高压患者的一种术式选择.     

腹腔镜下脾切除67例体会

目的 探讨腹腔镜下脾切除术的可行性和安全性。方法 回顾分析了2006年5月至2009年3月复旦大学附属中山医院普外科完成的67例腹腔镜下脾切除术临床资料,其中血液病26例,肝硬化、门静脉高压和脾亢25例,脾占位性病变16例。其中11例合并胆囊结石。 结果 67例病人平均脾脏切除时间2.2h,术中平均出血量83.9mL,术后平均住院时间6.4d。1例术后出血,8例术后引流液淀粉酶增高,其余病人无腹腔镜手术相关的术后并发症,无手术死亡。11例同时行腹腔镜胆囊切除术。13例巨脾病人行全腔镜下脾切除术。30例中转手助腹腔镜脾切除术,原因为：巨脾、肥胖、脾胰韧带极短、出血、粘连。1例门静脉高压病人中转开腹。结论 腹腔镜下脾切除术是安全可行的,适用于各种脾脏疾病。     

脾动脉主干结扎法腹腔镜巨脾切除术

目的探讨脾动脉主干结扎法在腹腔镜巨脾切除中的应用价值。方法在完全腹腔镜下完成16例巨脾切除术。在切脾前结扎脾动脉。结果 16例手术全部成功,无死亡病例。切脾时间60～210 min,平均160 min。术中出血30～220 ml,平均115 ml(不包括脾血)。7例术后出现少量腹水。术后胃肠蠕动恢复时间12～24 h,术后24 h拔胃管并进食流质饮食,术后住院时间5～9天,平均6.5天。结论脾动脉主干结扎法腹腔镜巨脾切除术在临床上是安全有效的。     

腹腔镜巨脾切除贲门周围血管离断术治疗门脉高压症

目的:探讨腹腔镜巨脾切除术的可行性和安全性。方法:2003年10月至2008年12月我院为11例脾长径大于25cm的肝硬化门脉高压、脾功能亢进、食道胃底静脉曲张患者施行腹腔镜巨脾切除加贲门周围血管离断术。结果:11例均顺利完成腹腔镜手术,无中转开腹,手术时间平均250min,平均出血430ml。结论:只要具备相应的手术设备,熟练掌握手术技巧,腹腔镜巨脾切除加贲门周围血管离断术安全可行。     

腹腔镜巨脾切除术12例临床分析

目的:探讨腹腔镜巨脾切除术的安全性及临床效果。方法:回顾分析12例腹腔镜巨脾切除术的临床资料。结果:12例中1例中转开腹,11例成功完成腹腔镜巨脾切除术,手术时间150~200m in(平均160m in),术中失血20~200m l(平均120m l),术后胃肠蠕动恢复时间12~24h,术后平均住院5.5d,无手术死亡病例,发生并发症3例,1例术后皮下气肿,1例术中降结肠损伤,1例术后门静脉血栓形成。结论:腹腔镜巨脾切除术安全可行,但必须具有良好的腹腔镜技术和开腹脾切除经验。     

手助腹腔镜巨脾切除术32例

目的探讨手助腹腔镜巨脾切除的安全性和可行性。方法对32例巨脾患者，采用手助腹腔镜技术行巨脾切除术．应用超声刀分离．脾门血管分别用生物血管夹、直线切割器夹闭或结扎。结果32例手助腹腔镜巨脾切除术均获得成功，单纯脾切除平均手术时间为128min，平均出血量115ml，脾均质量1439g，术后平均住院9．1d。全组术后均未发生并发症，无手术死亡。结论手助腹腔镜巨脾切除术是安全可行的微创手术方式。     

完全腹腔镜下巨脾切除术20例分析

目的探讨腹腔镜巨脾切除术的可行性、安全性及手术技巧。方法回顾性分析2006年8月至2009年7月20例腹腔镜巨脾切除术的临床资料。结果20例均顺利完成腹腔镜巨脾切除术。手术时间100—210min,平均140min。术中出血量20～650ml,平均80ml。术中切除副脾3个,同时行胆囊切除3例,肝活检术9例。全组术后6～12h拔除胃管、尿管并下床活动,12～24h肛门排气,1—2d恢复进食。有1例肝炎后肝硬化患者术后脾窝渗血再次剖腹脾窝止血,无手术死亡。平均住院时间7．8d。结论只要熟练掌握开腹巨脾切除术及腹腔镜技术,腹腔镜巨脾切除术是一种安全可行的微创手术方式,值得临床推广。术中脾周韧带的分离,脾蒂的处理是手术成功的关键因素。     

二级脾蒂离断法脾切除术在肝硬化门脉高压症脾功能亢进中的应用

目的:探讨肝硬化门脉高压症脾功能亢进轻中度脾肿大行腹腔镜下二级脾蒂离断法脾切除术的可行性、有救性和安全性.方法:对2009年1月至2010年12月施行腹腔镜下二级脾蒂离断法行脾切除治疗肝硬化门脉高压症脾功能亢进轻中度脾肿大25例患者的临床资料进行回顾分析.结果:除1例因大出血中转开腹外,均顺利完成手术.手术时间平均180 min,术中出血平均260 ml,无严重并发症.结论:肝硬化门脉高压症脾功能亢进轻中度脾肿大患者行腹腔镜下二级脾蒂离断法脾切除安全有效,值得临床推广应用.     

腹腔镜门脉高压症巨脾切除术脾蒂的处理体会

目的:探讨手助腹腔镜下巨脾切除的脾蒂处理方法和技术。方法:2003年2月~2006年3月共完成手助腹腔镜门脉高压症巨脾切除术33例。脾蒂的处理方法如下:直线切割缝合器23例,直视下结扎4例,血管闭合器(L igaSure)2例,钛夹2例,腔镜下结扎2例。结果:33例手术全部成功处理脾蒂,未发生脾蒂大出血。手术时间150~260m in,平均190m in。术中出血100~2 000m l,平均490m l。切除脾重500~2 000g,平均910g。术后32例恢复顺利,1例因肝功能衰竭死亡。结论:腔镜下巨脾切除术脾蒂处理十分关键,直视下结扎和应用直线切割缝合器处理脾蒂最为安全、有效。     

完全腹腔镜下乙肝肝硬化门脉高压性巨脾切除术的临床研究

目的:探讨腹腔镜下乙肝肝硬化门脉高压性巨脾切除术的临床应用效果及手术技巧。方法:回顾分析2015年9月至2017年6月为17例乙肝肝硬化门脉高压症巨脾患者行腹腔镜脾切除术的临床资料。结果:15例成功完成手术,1例因脾静脉破裂出血止血困难、1例因脾门粘连解剖困难中转开腹。手术时间150～220 min,平均(180.8±17.8) min;术中出血量500～1 500 mL,平均(770.54±156.78) mL,术后淡血性引流液总量10～120 mL,平均(58.6±37.6) mL。术中、术后均无并发症发生。结论:腹腔镜下门脉高压性巨脾切除术出血风险高,技术难度大,对术者腹腔镜下处理出血的技术及心理素质要求极高;但具有患者创伤小、美容效果好、手术并发症少、术后康复快等优点,值得推广应用。     

术前脾动脉栓塞对腹腔镜巨脾切除术影响的动物实验研究

目的:探讨腹腔镜巨脾切除术前脾动脉栓塞的价值及两种不同栓塞方法的效果。方法:10只健康家犬随机分为A组(脾动脉主干栓塞)和B组(全脾脏栓塞),成功建立巨脾模型后行脾动脉栓塞。于栓塞前、栓塞后1h、1d、7d、14d、28d分别将两组各一只动物剖腹观察脾脏大小改变及脾脏周围渗出、粘连情况,取栓塞部位组织送病理检查。结果:全组动物无死亡和并发症,均成功建立巨脾模型。栓塞后A组动物脾脏先缩小后增大,病理检查脾组织轮廓尚存,B组动物脾脏持续缩小,病理检查可见梗死灶。结论:栓塞后7d内行腹腔镜巨脾切除是可行和安全的,均可使巨脾缩小,降低手术操作困难,减少术中大出血的风险。     

Splenic artery embolization before laparoscopic splenectomy in children

Background This study assessed the safety and utility of preoperative splenic artery embolization before laparoscopic splenectomy in children. Methods Five young girls with a mean age of 13.2 years underwent laparoscopic splenectomies at the authors’ institution from August 1998 to April 2003. Three of the patients had idiopathic thrombocytopenic purpura, and two had hereditary spherocytosis. Preoperative splenic artery embolization was performed the day before the surgery in all cases. The laparoscopic splenectomy was performed using traditional laparoscopic procedures and standard laparoscopic instruments with the patient in the right semilateral position. Results The mean spleen weight was 252.6 g, and the mean length was 11.6 cm. All the patients reported postembolic pain, but not to a level unmanageable by intravascular narcotics. There were no severe complications in the splenic artery embolization. The laparoscopic splenectomies were completed in a mean of 211 min, with a mean estimated blood loss of 9 ml. None of the operations required conversion to traditional open laparotomy, and none of the patients died or experienced operative complications. Conclusion The authors concluded that splenic artery embolization is safe and useful as an adjuvant procedure performed before elective laparoscopic splenectomy in children.     

完全腹腔镜下脾切除联合贲门周围血管离断术的临床应用

目的 探讨完全腹腔镜下脾切除联合贲门周围血管离断术的适应证和临床应用价值.方法 分析对40例肝硬化门静脉高压症脾亢患者采用完全腹腔镜下脾切除联合贲门周围血管离断术的临床资料.结果 本组中36例顺利完成完全腹腔镜下脾切除联合贲门周围血管离断术,4例中转开腹,平均手术时间(224±54)min,平均术中出血量(296±209)ml,无严重并发症.结论 对门静脉高压脾亢患者选择性地采用完全腹腔镜下脾切除联合贲门周围血管离断术是一种可供选择的安全、有效的微创方法.     

Left-sided portal hypertension: Successful management by laparoscopic splenectomy following splenic artery embolization

INTRODUCTION

Left-sided portal hypertension is a rare clinical condition most often associated with a pancreatic disease. In case of hemorrhage from gastric fundus varices, splenectomy is indicated. Commonly, the operation is carried out by laparotomy, as portal hypertension is considered a relative contraindication to laparoscopic splenectomy (LS). Although some studies have reported the feasibility of the laparoscopic approach in the setting of cirrhosis-related portal hypertension, experience concerning LS in left-sided portal hypertension is lacking.

PRESENTATION OF CASE

A 39-year-old man was admitted to the Emergency Department for haemorrhagic shock due to acute hemorrhage from gastric fundus varices. Diagnostic work up revealed a chronic pancreatitis-related splenic vein thrombosis causing left-sided portal hypertension with gastric fundus varices and splenic cavernoma. Following splenic artery embolization (SAE), the case was successfully managed by LS.

DISCUSSION

The advantages of laparoscopic over open splenectomy include lower complication rate, quicker recovery and shorter hospital stay. Splenic artery embolization prior to LS has been used to reduce intraoperative blood losses and conversion rate, especially in complex cases of splenomegaly or cirrhosis-related portal hypertension. We report a case of complicated left-sided portal hypertension managed by LS following SAE. In spite of the presence of large varices at the splenic hilum, the operation was performed by laparoscopy without any major intraoperative complication, thanks to the reduced venous pressure achieved by SAE.

CONCLUSION

Splenic artery embolization may be a valuable adjunct in case of left-sided portal hypertension requiring splenectomy, allowing a safe dissection of the splenic vessels even by laparoscopy.     

Laparoscopic splenectomy for the treatment of gastric varices secondary to sinistral portal hypertension

Portal hypertension presents significant challenges to the laparoscopic surgeon. Here we review the case of a successful laparoscopic splenectomy in a patient with sinistral portal hypertension. The value of preoperative splenic artery embolization is highlighted.     

腹腔镜肝切除联合脾动脉结扎术治疗肝癌合并门脉高压症的疗效分析

目的探讨腹腔镜肝切除联合脾动脉结扎术治疗肝癌合并门脉高压症患者的安全性及有效性。方法2018年2月至2020年2月我院共手术治疗的28例原发性肝细胞肝癌合并肝炎后肝硬化、门脉高压症及脾功能亢进患者,在腹腔镜下先行脾动脉主干结扎、然后再行肝癌的切除,其中局部不规则切除19例、左肝外叶切除9例。回顾性分析患者的一般资料、手术过程、术后恢复及随访结果进行。结果28例手术均获成功,手术平均时间(102±40)min,术中出血量(71.07±79.41)mL,术后平均住院日(6.93±2.90)d。围手术期无死亡病例。术后无脾脓肿及肝衰竭等并发症发生,有5例腹水、2例胸腔积液、1例胆瘘、1例肺炎,均经非手术治疗后好转出院。白细胞及血小板计数术后1周恢复正常,至术后12个月仍维持在正常范围。截至2021年2月,门诊及电话随访12~36月,肝脏肿瘤再发3例次行射频消融治疗,多发肝内外转移死亡1例,上消化道出血死亡1例,失访1例。结论腹腔镜下肝癌切除联合脾动脉结扎术治疗肝功能相对较差的肝癌合并门静脉高压症脾功能亢进患者是安全可行的,且具有微创的优势。     

腹腔镜下门静脉高压症巨脾切除的手术技巧和风险评估（附九例报告）

目的探讨腹腔镜下门静脉高压症巨脾切除的手术技巧及手术风险评估。方法回顾性分析2011年6月至2011年10月实施腹腔镜下门静脉高压症巨脾切除手术9例的临床资料。结果本组成功施行全腹腔镜下手术6例,因出血中转开腹手术3例,手术中转率33．3％。无手术并发症发生,无死亡病例。结论腹腔镜下门静脉高压症巨脾切除病人术前要根据影像学检查进行评估,严格把握腹腔镜手术适应证,脾蒂的处理是全腹腔镜下手术成功的关键,术中大出血是腔镜手术失败中转开腹的主要原因。术中谨慎、耐心的操作,果断的判断中转手术时机对于确保病人安全最为重要。尽管风险很大,只要掌握好关键技术,腹腔镜下门静脉高压症脾切除还是安全、可行的。     

减少腹腔镜脾切除术术中出血的初步体会

目的探讨预防和减少腹腔镜脾切除术(laparoscopic splenectomy,LS)术中出血的手术技巧和措施。方法2008年1月～2010年3月行LS 40例。脾动脉位于胰尾上缘者,先分离并结扎脾动脉主干,离断脾周韧带;脾动脉位于胰尾后方或胰尾内者,先离断脾周围韧带和剥离胰尾,显露和离断脾蒂血管,完成LS。结果完成LS 31例,LS联合LC 7例,LS联合胆囊切除,贲门周围血管离断术2例。术中切除副脾3例。手术时间90～210 min,平均130 min;出血量50～800 ml,平均160 ml。术后12～24 h胃肠蠕动恢复,术后24 h拔胃管后进食。术后住院5～9 d,平均7.5 d。1例特发性血小板减少性紫瘢(idiopathic thrombocytopenic purpura,ITP)术后效果不佳,血小板一直<50×109/L,口服泼尼松20 mg/d维持治疗;23例ITP随访4个月～2年,平均1年,无复发;2例门脉高压症随访1年,未发生消化道出血。结论围手术期改善凝血,提高血小板计数,术前行脾动脉CT血管造影,手术时在胰腺上缘结扎脾动脉,分离脾周围韧带时避免撕裂脾包膜,妥善处理脾蒂血管,谨慎对待门脉高压症患者,可减少LS术中出血。     

Splenic autotransplantation for treatment of portal hypertension.

BACKGROUND: When total splenectomy is unavoidable it is important to preserve splenic function in some form in order to prevent the complications of asplenism. Splenic autotransplantation is a good alternative in such cases. We describe the use of splenic autotransplantation for the treatment of portal hypertension. METHODS: We carried out total splenectomy on 31 patients (21 men, 10 women), ranging in age from 21 to 68 years, with schistosomal portal hypertension. From each removed spleen, we took 20 fragments and implanted them on the greater omentum. This procedure was combined with abdominal portal-variceal disconnection. Transgastric running suture of the lower esophageal and gastric varices completed the treatment of portal hypertension. All patients underwent clinical, hematologic, immunologic and scintigraphic assessment. The results with respect to morbidity and mortality, and hematologic and immunologic findings were compared with those in 36 patients submitted to other splenic procedures. RESULTS: There was no complication related to the splenic implants and none of the patients died. Hematologic and immunologic findings were normal. Scintigraphy registered images of splenic tissue in all cases. CONCLUSION: The implantation of splenic fragments on the greater omentum seems to be a safe and useful procedure for maintaining splenic function after total splenectomy.     

腹腔镜脾动脉结扎联合贲门周围血管离断治疗肝硬化门静脉高压

目的探讨腹腔镜脾动脉结扎联合贲门周围血管离断治疗肝硬化门静脉高压的安全性及有效性。方法回顾性分析自2014年2月~2018年2月48例腹腔镜脾动脉结扎联合贲门周围血管离断术治疗肝硬化门静脉高压的临床资料。46例保守治疗止血成功后择期手术(Child-Pugh A级30例,Child-Pugh B级16例),内镜及药物止血失败行急诊手术2例(Child-Pugh C级)。结果48例均顺利实施完全腹腔镜手术。手术时间(104.7±4.2)min,术中出血量(106.0±16.4)ml。术中输血1例(2.1%)。无死亡,无术后输红细胞。术后住院时间(5.6±0.2)d。术后随访15~63个月,中位数42个月。1例(2.1%)术后34、47个月因门静脉高压性胃病黑便2次,保守治疗。其他患者均无呕血、黑便。结论在熟练掌握腹腔镜技术的基础上,腹腔镜脾动脉结扎联合贲门周围血管离断术治疗肝硬化门静脉高压安全、有效。