臀部联体儿的手术分离

目的 探讨臀部联体儿的术前评估、术前准备及手术分离方案.方法 对1例臀部联体双患儿(男性,胎龄37周,剖宫产,年龄3.5个月;属三胞胎中的两胞胎;体重共8.0 kg.两患儿具有独立的旧肢、肛门、阴茎,四肢均可独立活动)的联体情况进行分析,行X线片、MRI、B超、CT及三维重建、体感诱发电位(SEP)等检查显示双患儿L3以下腰骶椎棘突发育不全、椎板裂,L3以下硬膜囊共用,脊髓末段位于L3节段,脊髓无交叉共用,马尾神经未见明确的交叉,未见脊柱及骨盆的骨性连接,患儿各有独立的膀胱、直肠.测世共用硬膜囊的周长和而积,并进行术前评估,判断分离后硬膜可以直接缝合.术前进行多学科讨论和模拟手术演练,确定联体儿分离的手术方案.在全身麻醉下进行联体儿分离术,术中选择交叉"V"形皮瓣覆盖创面,硬膜囊连接部切断直接缝合.术后皮瓣张力不高,予皮瓣下持续负压引流,无菌敷料加压包扎.结果 联体儿成功分离,术后6 h患儿双下肢活动正常,术后第1天拔除伤口引流管,皮瓣血运可.无术后感染及脑脊液漏,无神经损伤.随访6个月,皮瓣愈合良好,两患儿生长发育及神经功能均正常.结论 完善的术前准备,准确的术前评估,仔细的术中操作,严密的术后管理,周密的学科协作,是臀部联体儿分离手术成功的关键.

The surgical separation of pygopagus conjoined twins

Objective To explore the program of preoperative evaluation, preoperative preparation and separation operation of pygopagus conjoined twins. Methods Clinical data of one case of pygopagus ( male, gestational age 37 weeks, uterine-incision delivery, 3. 5 months old ; twins of triplets ; total body weight 8.0 kg. The twins have self-governed extremities, anus, penis. Four limbs can move independently). Separated successfully were analyzed. The auxiliary examination of X-rays, MRI, ultrasound, CT and 3D reconstruction, sensory evoked potential showed that there were process hypoplasia and lamina bifid of lumbosacral vertebrae below L3. Dural sac connected below L3 and conus medullaris located at L3. There were no conjunction of spinal cord and cauda equine. The decision of direct suture of dural sac was made by preoperative evaluation through measurement of circumference and area of conjoined dural sac. The separation surgery program was decided through team debate and sham operation. Separation operation was performed under the general anaesthesia. Crossing V-shaped skin flap was used to cover the wound surface. The dura of conjoined twins were sutured directly. The tension of skin flap was normal postoperative with continuing negative pressure drainage under the flap and pressure sterilized dressing. Results Successful separation of pygopagus conjoined twins was achieved. Lower extremities movements of separated twins were normal 6 h after operation. The drainage was removed 1 day postoperative, blood supplies of skin flap were normal. There were no complications of infection, cerebrospinal fluid leakage and neurological deficit. The healing of the skin flap was good. With 6 months follow-up, the growth and neurological function were normal. Conclusion Consummate preoperative preparation, accurate preoperative investigations, meticulous operative management, careful postoperative administration and good team cooperation are the keys to successful separation of pygopagus conjoined twins.