腹腔镜胃癌根治术出血的预防和处理

腹腔镜胃癌手术具有创伤小、术中出血少、术后胃肠功能恢复快和住院时间短等微创优势,已在临床广泛开展。厦门大学附属中山医院胃肠外科2009年7月至2011年12月共计对312例胃癌患者施行了腹腔镜胃癌根治术。有10例患者发生了术中出血,3例术后出现腹腔内出血。均成功救治。现总结这组病例资料,对腹腔镜胃癌手术中和术后常见出血的预防措施及处理原则进行探讨。     

腹腔镜远端胃癌D2根治术中胃周血管的解剖概要

腹腔镜手术以其显著的微创优势已成为外科医生治疗早期胃癌的首选方式之一。随着腹腔镜手术经验的不断积累,腹腔镜远端胃癌D：根治术已逐步应用于治疗进展期胃癌。然而,该术式在技术层面的要求高,尤其是在进行D2淋巴结清扫时,对于准备开展该术式的外科医生而言．术中突发的出血状况往往是阻扰他们顺利进行手术的原因之一。因此,熟练掌握胃周血管的解剖对安全有效地实施腹腔镜远端胃癌D2根治术是必需的。     

腹腔镜辅助胃癌根治术中出血的相关因素分析及处理策略

<正>腹腔镜辅助胃癌根治术创伤小、疼痛轻、出血量少、恢复快,与开腹胃癌根治手术相比,近、远期效果无差异~([1-2])。随着腹腔镜技术的提高和设备的更新,目前腹腔镜辅助胃癌根治术已在国内广泛开展。但与其他腹腔镜手术一样,腹腔镜辅助胃癌根治术亦面临术中出血影响操作及预后的问题。本研究回顾性分析2014年1月至2016年1月我院97例腹腔镜辅助胃癌根治病人的临床资料,探讨腹腔镜辅助胃癌根治术中出血的相关因素以及术中     

腹腔镜胃癌根治术后出血的原因与处理策略

腹腔镜胃癌根治术逐步得到重视,而术后出血是严重的并发症之一。本文对腹腔镜胃癌根治术后出血的高危因素、临床表现、预防及处理措施等进行阐述,并总结北京大学肿瘤医院胃肠外科近年来的经验,供同道参考。     

腹腔镜D2胃癌根治术术中出血原因与防治

目的探讨腹腔镜下胃癌根治术术中出血并发症的原因分析及防治。方法回顾性分析2013年4月至2014年12月施行腹腔镜下胃癌根治性切除手术146例,对术中出血情况进行统计分类,处理方法归类并分析出血原因,总结防治措施。结果本组146例中,平均出血量(88±72.1)ml,7例(4.79%)发生术中大出血(出血量大于300 ml),其中3例因为超声刀误伤导致胃右动静脉或胃十二指肠动脉出血,2例患者因为肥胖、暴力牵拉导致胃网膜左动静脉或胃周实质性脏器损伤出血,1例患者因为肥胖、肿瘤侵犯导致脾动静脉出血达500 ml,为本研究最大出血量,所有出血均在腹腔镜下采用夹闭、电凝、缝扎等止血方法成功止血,无1例中转开腹。结论出血是腹腔镜下胃癌根治术术中的常见的并发症之一,患者和术者两方面因素共同决定手术中的出血量,术中一旦发生出血,在助手充分暴露术野的前提下,执行"5P"原则止血。     

腹腔镜辅助胃癌根治术的临床应用(附36例报告)

目的:探讨开展腹腔镜辅助胃癌根治术的临床安全性及可行性。方法:回顾分析2010年5月至2012年10月36例腹腔镜辅助胃癌根治术患者的临床资料,总结分析患者年龄、临床分期、手术方式、切除范围、手术时间、术中出血量、术后肛门排气时间、并发症及术后随访等情况。结果:36例患者均顺利完成腹腔镜辅助胃癌根治术,无一例中转手术。手术时间平均(220.4±35.7)min,术中出血量平均(115.7±40.3)ml,平均清扫淋巴结(14.3±4.2)枚,胃肠道功能平均恢复时间(81.6±15.6)h,下床活动时间平均(71.1±16.2)h。全组患者无吻合口漏、出血、切口感染等手术并发症发生,术后随访无切口种植。结论:对于早期胃癌或较早的进展期胃癌,腹腔镜辅助胃癌根治术是安全、可行的,手术近期疗效满意,远期疗效尚待进一步观察。对于进展期胃癌,腹腔镜术式的应用及临床疗效仍需进一步探索。     

早期开展腹腔镜胃癌手术的并发症分析

目的探讨早期开展腹腔镜胃癌手术出现的并发症及预防、治疗措施。方法回顾性分析2009年6月-2010年6月50例腹腔镜胃癌D2手术的临床资料,包括手术方式、中转开腹率、手术时间、术中出血量、手术并发症等。腹腔镜下行D2淋巴清扫,上腹小切口切除标本并消化道重建。结果完成腹腔镜手术42例,无围手术期死亡,中转开腹率16%（8/50）。术中并发症发生率8%（4/50）,其中重要血管损伤引起出血3例,横结肠系膜损伤1例;术后早期并发症发生率14%（7/50）,其中腹腔内出血1例,十二指肠残端漏1例,残胃排空障碍3例,术后切口感染1例,支气管肺炎1例。结论掌握腔镜下特有的解剖层面,提高手术技巧,建立规范的操作步骤,加强团队配合,是防治腹腔镜胃癌手术并发症的关键。     

腹腔镜远端胃癌D2淋巴结清扫术可行性分析

目的：探讨腹腔镜辅助胃癌D：淋巴结清扫术的安全性及可行性。方法：回顾分析2010年1月至2012年6月为363例患者行腹腔镜远端胃癌耽根治术（腹腔镜组）的临床资料,并与2008年1月至2010年1月412例开放远端胃癌D：根治术（开腹组）进行对比分析。结果：两组患者清扫淋巴结数量、近端切缘距肿瘤距离、远端切缘距肿瘤距离、手术时间、住院时间差异无统计学意义（P〉0．05）;但腹腔镜组术中出血量优于开腹组（P〈0．05）。腹腔镜组术后随访2—27个月,无一例腹壁切口肿瘤种植及复发。结论：腹腔镜胃癌D,根治术治疗进展期胃癌可达到与开放手术相同的肿瘤根治效果,是安全、可行的：较开放手术出血少、康复快,是治疗进展期胃癌的有效术式。     

腹腔镜下胃癌根治术后迟发性出血4例分析

目的:分析腹腔镜下胃癌根治术后迟发性出血原因,探讨减少术后迟发性出血的方法及预防处理措施。方法:结合文献并总结分析近期4例腹腔镜下胃癌根治术后迟发性出血的临床资料。结果:2例手术治疗,1例经DSA定位TEA治疗,1例保守治疗,均顺利出院。结论:腹腔镜下胃癌根治术后迟发性出血病因复杂,一旦发生必须争分夺秒进行手术或血管栓塞,以挽救生命。     

腹腔镜胃癌根治术47例

自1993年Azagra等[1]完成首例腹腔镜胃癌手术以来,腹腔镜胃癌根治术逐渐开展,但目前仍处于探索阶段。本文回顾性分析我院2007年2月—2010年2月开展的47例腹腔镜胃癌根治术患者的临床资料,就其术式选择进行探讨。     

Early laparoscopic management of acute postoperative hemorrhage after initial laparoscopic surgery

BACKGROUND AND PURPOSE: The use of laparoscopic surgery has been well established for the management of abdominal emergencies. However, the value of this technique for postoperative hemorrhage in urology has not been characterized. We present our favorable experience with laparoscopic exploration after urologic surgery and suggest guidelines for laparoscopic management of post-laparoscopy bleeding. PATIENTS AND METHODS: Three patients who developed hemorrhage shortly after laparoscopic urologic surgery and were managed by laparoscopic exploration were identified from a series of 910 laparoscopic urologic procedures performed at our institution from October 2002 to June 2006. RESULTS: Three patients, who were hemodynamically stable (two after robot-assisted laparoscopic prostatectomy, one after laparoscopic radical nephrectomy), required prompt surgical exploration for postoperative hemorrhage not stabilized by blood transfusion (mean 2.7 units) at a mean of 19.4 hours after initial surgery. Clots were evacuated with a 10-mm suction-irrigator. Two patients were found to have abdominal-wall arterial bleeding and were managed with suture ligation. The third patient demonstrated diffuse bleeding from the prostatic bed, which was controlled with Surgicel and FloSeal. Bleeding was efficiently controlled in all patients, and none required post-exploration transfusion. The mean post-exploration hospital stay was 2.3 days. CONCLUSION: Significant hemorrhage after urologic laparoscopy is a rare event. We found laparoscopic exploration to be an excellent way to diagnose and correct such hemorrhage in certain patients. Early diagnosis with clinical and hematologic studies, a lowered threshold for surgical exploration, and specific operative equipment may decrease patient morbidity and the need for open surgical exploration.     

Surgical clip found in duodenal ulcer after laparoscopic cholecystectomy

The wide use of surgical clips in laparoscopic surgery has led to a variety of complications. We describe two cases in which a surgical clip was incorporated into a duodenal ulcer after laparoscopic cholecystectomy. The presenting symptom was acute gastrointestinal bleeding. Both patients were treated endoscopically, and the bleeding stopped after the clip was removed from the ulcer base. Although the mechanism by which a surgical clip migrates into the duodenum is unclear, we recommend meticulous Calot's triangle dissection and removal of any wandering or misplaced clips. Endoscopic removal is recommended when a surgical clip is discovered in a bleeding ulcer.     

Laparoscopic temporary packing for hemostasis

Control of bleeding from the renal parenchyma remains one of the challenges of laparoscopic partial nephrectomy. If adjuvant measures fail, packing of the surgical bed may achieve hemostasis. We report a novel series of temporary laparoscopic packing of the surgical bed with minimally invasive kidney surgery. Technique and potential complications are also discussed.     

Minimally invasive treatment of obscure gastrointestinal bleeding using laparoscopic ultrasonography

The management of patients with small bowel bleeding remains a diagnostic and therapeutic challenge because sensitive methods are lack and identifying the etiology and site of hemorrhage is essential in determining appropriate therapies. Accurate localization of small bowel lesions causing obscure bleeding is essential for the successful surgical treatment. However, if the lesions are small and intraluminal nature, it is impossible to identify the lesions by laparoscopy alone. We report a novel approach using the combination of laparoscopic surgery with laparoscopic ultrasonography, which enables successful minimally invasive treatment of obscure gastrointestinal bleeding caused by a submucosal tumor in proximal ileum.     

腹腔镜肝切除术中出血的风险因素及对策

出血是腹腔镜肝切除术中须面对的难题，也是限制腹腔镜肝切除术推广普及的重要因素，且出血和输血增加了术后并发症发生和肿瘤复发的风险。腹腔镜肝切除术中出血的风险因素包括：肝脏基础疾病背景，肿瘤大小、部位、性质，手术路径及操作技巧，术中液体及麻醉管理等。腹腔镜肝切除术中出血重在预防，严格把控手术适应证，基于三维可视化评估及手术规划，选择正确手术路径及导航方法，通过精细手术操作、肝血流阻断及控制性低中心静脉压（CVP）等对策能显著降低术中出血风险。娴熟的腹腔镜缝合技术及得力的助手配合是处理腹腔镜肝切除术中出血的终极手段。     

Exploration for hemorrhage following laparoscopic renal surgery: intraoperative findings

PURPOSE: Bleeding after surgery is a rare but potentially life threatening complication. We reviewed operative and postoperative clinical features in patients who required surgical exploration secondary to hemorrhage following laparoscopic renal procedures. MATERIALS AND METHODS: We retrospectively reviewed the records of patients undergoing laparoscopic renal surgery between January 1996 and September 2004. Nine of 1,123 patients (0.8%) underwent early exploration for bleeding within 5 days of surgery. RESULTS: Two groups were identified. Group 1 consisted of 4 patients who underwent early exploration at less than 10 hours after surgery and had arterial bleeding. Group 2 consisted of 5 patients who underwent exploration a mean 38 hours after surgery and in whom no bleeding source was identified. Group 1 patients had pronounced hypotension with systolic blood pressure 70 to 79 mmHg and hematocrit decreases (mean 10.5%) in a short time course before repeat exploration (mean 4.5 hours). Arterial bleeding was identified in the hilum and adrenal bed. Group 2 patients demonstrated a decrease in hematocrit from an initial mean of 28.3% to 22.5% with tachycardia and mild hypotension (systolic blood pressure 90 to 99 mmHg). On exploration group 2 patients had diffuse oozing. Mean hospital stay in group 1 was 8 days (range 4 to 9) vs 12 (range 6 to 24) in group 2. CONCLUSIONS: Early hemodynamic instability after laparoscopic renal surgery is likely to indicate a discrete arterial bleeding source from the hilum or adrenal bed, requiring surgical control. In patients who underwent exploration after a delayed bleeding presentation no discrete source was found intraoperatively. Therefore, it is unclear whether these patients benefited from surgical exploration.     

Anesthesia management for laparoscopic prostatectomy and open prostatectomy

BACKGROUND: For anesthetic management of traditional open prostatectomy, preparation for hemorrhage is necessary. However, it has been considered that the amount of bleeding under laparoscopic prostatectomy is less than that of traditional open surgery. METHODS: The amount of bleeding and autologous blood preparation, fluid balance, and anesthetic management were investigated in patients who had undergone laparoscopic or open prostatectomy at the Nippon Medical School Hospital between June, 2004 and November, 2005, retrospectively. The difference of these aspects between the two surgical method groups was evaluated. RESULTS: Thirty-two patients underwent prostatectomy in the investigation period. In these patients, 4 patients were excluded due to incomplete anesthesia record or change of surgical method. The amount of bleeding, and both amount of autologous blood preparation and transfusion in the laparoscopic surgery were less than those in the open surgery. There were no significant differences in the fluid balance and amount of urine output between the two groups. CONCLUSIONS:We conclude that preparation of autologous blood transfusion is necessary for the traditional open prostatectomy, but not for the laparoscopic prostatectomy.     

腹腔镜直肠癌手术常见并发症的预防与处理原则

腹腔镜直肠癌手术相关并发症的预防与治疗是手术成功和术后恢复的关键。腹腔镜直肠癌根治术常见腹部并发症有腹腔内出血、腹腔脏器损伤、神经损伤、吻合口漏、出血、狭窄等。笔者结合该领域相关现状和自身经验,对腹腔镜直肠癌手术常见腹部并发症的防治及其处理原则作一总结与分享。     

Applications of FloSeal in nephron-sparing surgery

Hemostasis can be a challenging problem to control laparoscopically. We advocate the use of FloSeal Matrix. FloSeal can be used in a variety of open and laparoscopic procedures, including laparoscopic or open partial nephrectomy. FloSeal was highly effective in stopping bleeding in a bloody surgical field.     

Stromal tumors of the jejunum and obscure gastrointestinal bleeding. Use of minimally invasive techniques in three cases

Gastrointestinal bleeding is considered to be obscure when routine endoscopic techniques (esophagogastroscopy and colonoscopy) fail to identify the origin of the hemorrhage. These hemorrhages represent 5% of all gastrointestinal bleeding. Twenty-seven percent of these hemorrhages are due to small bowel disease and gastrointestinal stromal tumors (GIST) are a frequent cause, especially in middle-aged patients. We present three cases that illustrate the difficulty of diagnosing this clinical entity. We emphasize the use of minimally invasive techniques such as computed tomography and laparoscopic surgery in the complicated management of these patients. We believe that the use of these techniques could avoid the need for other more aggressive procedures and allow the application of early definitive surgical treatment with the advantages of laparoscopic surgery.