腹腔镜手术出血并发症的原因分析

目的:分析腹腔镜手术发生出血并发症的原因。方法:回顾分析施行腹腔镜手术过程中发生出血并发症22例的临床资料。结果:依手术时间可分为术中出血17例,术后出血5例,依出血位置可分为腹壁出血8例,手术区域出血14例。结论:手术操作仔细和及时处理是避免出血并发症的关键。     

Thoracic complications during urological laparoscopy

PURPOSE: We documented thoracic related complications during urological laparoscopic surgery. MATERIALS AND METHODS: A total of 1129 patients underwent major urological laparoscopic procedures in a 5-year period. Operative reports and postoperative radiographic reports were retrospectively reviewed to identify patients with thoracic related medical and surgical sequelae. Of the patients 619 (55%) underwent at least 1 chest x-ray in the immediate or early postoperative period. In the remaining 510 patients (45%) there was no clinical indication to perform chest x-ray. RESULTS: Of 619 patients undergoing chest x-ray 438 (71%) were completely normal. Medical pulmonary complications, surgical thoracic complications and subclinical, incidentally detected gas collections in the chest were identified in 12.6%, 0.5% and 5.5% of patients, respectively. Medical complications in 12.6% of cases included pulmonary infiltrate/atelectasis in 9.7%, pleural effusion in 4.8% and pulmonary embolus in 0.3%. Surgical complications included symptomatic pneumothorax in 4 patients (0.35%), hemothorax in 1 (0.08%) and chylothorax in 1 (0.08%). Subclinical abnormal thoracic gas collections were radiographically noted in 34 of the 619 patients (5.5%) on chest x-ray, including pneumomediastinum in 19 (3.1%), pneumothorax in 10 (1.6%) and pneumopericardium in 5 (0.8%). Overall 36 of 40 (90%) thoracic surgical complications (3) and subclinical, incidentally detected gas collections (33) occurred during retroperitoneal laparoscopy. Re-intervention was necessary in 6 patients (0.5%), namely pulmonary embolus requiring vena caval filter placement in 3 (0.3%), pneumothorax requiring a chest tube in 2 (0.17%) and hemothorax requiring emergency open thoracotomy in 1 (0.08%). No patient underwent open conversion to complete the initial proposed operation. CONCLUSIONS: Due to its high solubility the expectant management of incidental CO2 pneumothorax, pneumopericardium and pneumomediastinum is recommended initially in the clinically stable patient. Inadvertent diaphragmatic entry can be satisfactorily repaired laparoscopically without open conversion. Although it is rare, surgical thoracic complications are potentially life threatening, requiring prompt identification and management.     

腹腔镜技术在肠道血管畸形急性出血中的应用体会

目的:探讨腹腔镜技术诊治肠道血管畸形急性出血的临床价值。方法:回顾分析为13例保守治疗无效的小肠血管畸形急性出血患者行腹腔镜辅助手术的临床资料。结果:13例患者术前选择性行肠系膜数字减影血管造影(digital sub-traction angiography,DSA)。造影定位下行腹腔镜辅助小肠部分切除吻合术10例,回盲部切除末端回肠造口术1例;术中造影无法明确,内镜协助探查明确出血部位,腹腔镜辅助下行小肠切除吻合1例;导管造影及内镜协助探查均无法明确出血部位,行小肠双口造瘘观察1例。12例痊愈出院,1例死亡。结论:DSA及术中造影是诊断小肠出血并准确定位的有效方法,为外科手术提供了正确的定位。DSA及术中造影准确定位后行腹腔镜辅助手术切除病变肠段安全、有效。     

Trocar-induced complications in laparoscopy

Trocar-related injury can occur if the different procedures, including distension of the abdomen, pneumoperitoneum or anesthesia, are insufficient. Such injuries can be prevented by proper handling and good angulation of the trocar on the abdomen. In case of suspected vascular injury, conversion to open laparotomy is required to explore the abdominal cavity. If abdominal adhesions are discovered after introducing the first trocar, a second trocar must be introduced at some distance from the first one to visually check the absence of any digestive injury. The degree of wound dehiscence depends on the size, site and direction of introduction of the trocar.     

Vascular complications during laparoscopy. An analysis of a personal case]

Vascular complications of laparoscopy most often occur during Veress needle or primary trocar placement. Veress needle punctures are insignificant and require no further treatment, whereas trocar induced vascular injuries can be catastrophic. The frequency of vascular or viscus injuries is difficult to calculate since several complications are not published. A vascular complication occurred in a young girl with neurologic problems and a kyphoscoliosis operated on in laparoscopy for a gastroesophageal reflux is discussed. After the establishment of pneumoperitoneum, an important hemoperitoneum was rapidly evident at insertion of the laparoscope. An open laparotomy was performed showing right common iliac vessel injuries and several intestinal perforations. After a complex vascular reconstruction and a multiple intestinal suture, the Nissen fundoplication with pyloroplasty was performed traditionally and the patient leave the hospital free of symptoms after 20 days. In laparoscopy, as in all areas of surgery, experience knowledge and meticulous attention to details are the most important factors in order to avoid complications. The authors believe that the open approach with Hasson cannula is the most important factor in avoiding complications.     

腹腔镜胆囊切除术中胆囊动脉出血的处理体会

目的:探讨腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)术中胆囊动脉损伤出血的原因及处理方法。方法:回顾分析2013年1月至2016年8月12例LC术中胆囊动脉损伤出血患者的临床资料。结果:12例均在腔镜下进行妥善止血处理,并完成LC,无中转开腹。手术时间30~150 min,平均(87.60±17.40)min;术中出血量30~150 ml,平均(63.10±11.20)ml;术后2~5 d出院,平均(5.10±0.67)d。术后患者均获随访,随访6~24个月,平均(18.4±2.1)个月,患者均恢复良好,无并发症发生。结论:LC术中引起胆囊动脉损伤出血的原因是多方面的,既有解剖因素,也有病理因素及术者操作技术因素等,而且有时是多种因素共同作用的结果。术中损伤胆囊动脉或其分支引起出血时,术者应沉着冷静,切忌在视野不清的情况下慌乱钳夹电凝止血,应根据术中血管损伤的具体情况、术者经验与操作技能,个体化地进行止血处理。     

A review of perioperative complications during frameless stereotactic surgery: our institutional experience

Purpose  Frameless stereotactic neurosurgery is increasingly being used for the biopsy of intracranial tumors and the resection of deep-seated lesions where reliance on surface anatomic landmarks can be misleading, as well as in movement disorders, psychiatric disorders, seizure disorders, and chronic refractory pain. Nascent biological approaches, including gene therapy and stem-cell and tissue transplants for movement disorders, also utilize neuronavigational techniques. These procedures are complex and involve understanding of the basic principles and factors affecting neuronavigation. The procedure may appear to be simple, but serious complications may occur. Methods  The purpose of this study was to review the intraoperative and postoperative complications occurring during frameless stereotaxy at our institution from January 2003 to July 2007. Results  Seventy-eight patients underwent various neurosurgical procedures under general anesthesia. Intraoperative complications seen were intraoperative brain bulge (n = 3), seizures (n = 3), failure to extubate (n = 4), and fresh neurodeficits (n = 6). No hemodynamic disturbances such as hypertension or hypotension or bradycardia or tachycardia requiring active intervention were observed. Conclusion  Awareness and vigilance can help in the early identification and better management of the above intraoperative complications.     

Pneumothorax during laparoscopy

Background: Pneumothorax is a known complication of laparoscopy, with most pneumothoraces diagnosed postoperatively with conventional chest x-ray. Electrocardiogram (ECG) conduction changes are associated with pneumothorax. In a sheep model, ECG changes were evaluated as a potential indicator of intraoperative pneumothorax. Additionally, resolution rates of helium (He) and carbon dioxide (CO₂) pneumothorax were also evaluated in this model.Methods: Under general anesthesia, 10 sheep had known volumes (20–100 cc) of either He or CO₂ introduced into the left hemithorax. A 12-lead ECG recorded changes associated with the induced pneumothorax. After changes in the ECG plateaued, the gas volume in the hemithorax was increased to 2 L and the resultant pneumothorax was followed for a 2-h period using fluoroscopy to determine resolution rates for the different gas pneumothoraces. Gas volumes were aspirated after 2 h and ECGs were again recorded.Results: Pneumothorax volumes as low as 20 cc produced consistent ECG changes. The amplitude of the precordial QRS complex was seen to diminish, and this lowering of the QRS amplitude continued as pneumothorax volume increased up to 100 cc. The ECG returned to prepneumothorax patterns with aspiration of the left chest. For different gas pneumothoraces, CO₂ pneumothorax showed almost complete resolution in the 2-h period, whereas He pneumothorax was unchanged.Conclusions: Precordial ECG changes appear to be a very sensitive indicator of pneumothorax, with very small pneumothorax (<100 cc) consistently being detected by reduction of the QRS complex amplitude. Intraoperative use of precordial ECG leads could result in rapid identification of pneumothorax during laparoscopic surgery. Carbon dioxide pneumothorax shows near 100% resolution in a 2-h period. This supports recommendations of expectant management in asymptomatic patients with CO₂ pneumothorax. However, He pneumothorax does not resolve spontaneously quickly and may require aspiration even in asymptomatic patients.     

腹腔镜联合双气囊小肠镜在小肠出血中的诊断和治疗

目的评价腹腔镜对小肠出血的诊断与治疗。方法回顾性分析2003年9月～2005年12月间39例腹腔镜诊治小肠出血的临床资料,并对腹腔镜手术时间、术中失血、切口长度、术后排气时间、术后住院天数、并发症进行统计分析。结果腹腔镜不仅明确所有39例小肠出血的诊断,而且同时实施相应的腹腔镜手术。腹腔镜手术时间为70.3±32.6min,术中失血为16.1±12.4ml,切口长度为3.6±1.3cm,术后排气时间为2.3±0.8d,术后住院天数为7.9±3.1d。2例(5.1%)术后出现吻合口糜烂出血和束带粘连性小肠梗阻的并发症。结论腹腔镜不仅对小肠出血具有很高的诊断价值,而且可以实施安全、可行、微创的手术治疗。     

Endoscopy during laparoscopy

BACKGROUND: Intraluminal endoscopy during laparoscopy can substitute for manual palpation in defining anatomy and pathology, but a potential problem is the persistent bowel distention associated with intraluminal air insufflation. METHODS: To compare the rates of intraluminal absorption, a 30-cm segment of small bowel with an intact vascular supply was insufflated with either air or CO2 during CO2 pneumoperitoneum. Intraluminal pressures and bowel circumferences were monitored after the insufflation was stopped. To study the metabolic and hemodynamic effects of CO2 endoscopy during laparoscopy, the small bowel was insufflated to an intraluminal pressure of 15 mmHg during CO2 pneumoperitoneum. Nitrogen pneumoperitoneum was used to differentiate the effects from intraluminal and peritoneal CO2 insufflation. RESULTS: The intraluminal pressures remained elevated and the bowel distended for the entire 3 h following bowel insufflation with air. Following intraluminal CO2 insufflation, both the intraluminal pressures and the bowel circumferences returned to preinsufflation values within 15 min. Intraluminal CO2 insufflation also led to systemic absorption of CO2 with significant metabolic and hemodynamic changes. These changes were effectively corrected by doubling minute ventilation. CONCLUSIONS: Intraluminal CO2 was absorbed faster than intraluminal air. Although decreased bowel distention is certainly of practical value, endotracheal intubation needs to be done to effectively ventilate the absorbed CO2.     

经阴腹腔镜手术的初步应用体会

目的:探讨经阴腹腔镜手术的应用价值和操作方法.方法:2006年10月至2008年10月为20例阴式手术患者术前、术后经阴道插入腹腔镜,观察腹腔和盆腔脏器.结果:20例均成功建立气腹,并观察到盆腹腔脏器,手术成功率100%.经阴道手术前、后用腹腔镜观察盆腹腔脏器,手术时间增加6～10min,平均7min;总手术时间35～...     

A review of laparoscopy for non-obstetric-related surgery during pregnancy

PURPOSE: Similar to the general population, parturients (and their fetuses) could benefit from the reduced manipulation associated with laparoscopy. The purpose of this article is to review the current state of knowledge (both clinical and experimental) with respect to the fetal effects of maternal laparoscopy for non-obstetric-related surgery during pregnancy. METHODS: Human and experimental animal results are examined, and we present preliminary data from our own laboratory. CONCLUSIONS: Future experiments are proposed to further develop and refine standards of care for general surgeons and obstetricians who are presented with gravid females in abdominal distress.     

Circulatory collapse during laparoscopy

This case report details the intraoperative course of a patient, in her early pregnancy, who had a cardiac arrest during transvaginal insufflation of carbon dioxide (CO2) for laparoscopic tubal ligation. Modern monitoring methods and their ability to detect gas embolism and aid in the diagnosis and treatment of this rare but life-threatening complication are discussed.     

Hydrothorax during diagnostic laparoscopy

An 83-yr-old, 44-kg woman with a 2-month history of abdominal distension received diagnostic laparoscopy. Except for chronic treated hypertension, she was healthy. The preoperative chest X-ray demonstrated small pleural effusion occupying the lower left hemithorax, but she did not present with dyspnea or chest pain. After premedication with intravenous ranitidine 50 mg, anesthesia was induced with thiopental 150 mg, vecuronium 7 mg and maintained by 1-2% sevoflurane in 50% N2O/O2. SpO2 decreased after insufflation of CO2, but breath sound was audible on both lungs. At completion of operation, chest X-ray revealed the left hemilateral hydrothorax and 650 ml of pleural fluid was suctioned. Blood gas improved and the tracheal tube was removed. The diagnosis of tuberculous peritonitis was established by the demonstration of granulomas of the peritoneum. We speculated on four reasons for the increased pleural effusion on the left thorax: 1) Increase of systemic and capillary pressure caused by CO2 insufflation. 2) Increase of capillary permeability by tuberculous pleuritis. 3) Decrease of colloid osmotic pressure by hypoalbuminemia. 4) Decreased pleural fluid removal because of venous compression caused by increased intrathoracic pressure. Peritoneal insufflation of CO2 to create the pneumoperitoneum may induce hydrothorax in patients with tuberculous pleuritis.     

Initial experience with carbon dioxide laser laparoscopy

Adhesions and endometriosis are commonly encountered among patients presenting with pelvic or lower abdominal pain and also in a significant proportion of infertile patients. Laparoscopic investigation is usual in patients with these problems, and it has been possible to perform endoscopic surgery with special scissors and electrodiathermy. These methods can cause troublesome bleeding, and the diathermy produces high temperatures which can be hazardous if used in the vicinity of the bowel. The carbon dioxide laser can be used endoscopically to vaporize deposits of endometriosis and adhesions with great precision and virtually no bleeding. One hundred consecutive patients with endometriosis or adhesions were treated with the CO₂ laser laparoscope and followed up for at least a year. Seventy-five per cent of patients with pain due to endometriosis were cured, and 68% of patients were better after laser laparoscopic adhesiolysis. Pregnancy rate in the previously infertile group with endometriosis was 64%. There were no complications due to the intra-abdominal use of CO₂ laser energy under endoscopic control, although there is a need for a controlled trial. It appears that in the hands of an experienced laparoscopist this technique is safe and effective.     

Gas embolism during laparoscopy

The use of laparoscopic surgery has grown considerably, and the occurrence of some accidents, albeit rare, is now reported. Among them, gas embolism can induce a bad postoperative outcome. We report seven cases of carbon dioxide embolism (CO₂) during laparoscopic surgery. In the seven cases gas embolism occurred during insufflation or a few minutes later. All the patients had a previous abdominal or pelvic surgical history. Five patients presented cardiac bradycardia or arrhythmia. Cardiovascular collapse or cyanosis was the first manifestation in three cases. Sudden bilateral mydriasis was the earliest neurologic sign, present in five cases. Finally, the gas embolism complication was lethal in two cases. In summary, this study strongly stresses the need for precise rules of prevention of gas embolism, and close monitoring of cardiac rhythm during insufflation of carbon dioxide. The patients who had previous surgery should be considered as a risk population.     

Electrical injuries during laparoscopy

Electrical injury is uncommon during surgical laparoscopy, but may be serious. Following a comprehensive literature review, we describe five mechanisms of burn injuries: direct contact, electric arc, insulation failure, direct or capacitive coupling. We discuss these mechanisms and suggest simple preventive measures designed to ensure optimal safety.