腹腔镜腹膜透析管置入术在慢性肾衰竭合并腹部手术后患者中的应用

目的研究既往有腹腔手术、腹膜炎等特殊情况的慢性肾功能不全患者安全有效的腹膜透析管置入方法。对象与方法对第二军医大学长海医院肾内科符合CKD5期诊断标准8例患者,均有下腹部手术史或腹膜炎病史。手术方法为经脐下切1cm的弧形切口,插入5mm圆锥套管针(Trocar),以此孔做为观察镜通道,初步了解腹腔内情况。如患者有脏器粘连等情况,则在右侧腹直肌旁、脐下2cm处插入另一5mmTrocar为辅助操作孔,用以插入切割器,分离粘连组织,使用无损伤抓钳在屏幕直视下置入腹膜透析管。如无粘连等情况,则直接经操作孔置入腹膜透析管。结果2例患者应用切割器分离粘连的组织,4例患者借助无损伤抓钳使腹膜透析管放入膀胱直肠窝或子宫直肠窝,4例患者直接经操作孔道丝引导置入腹膜透析管。腹膜透析液进出通畅,无明显并发症发生。结论腹腔镜下置管术能在直视下将导管放入膀胱直肠窝或子宫直肠窝,是为有过腹腔手术或腹膜炎的患者置入腹膜透析管的有效方法。

Application of laparoscopic peritoneal catheters placement in CAPD patients with history of lower abdominal operation

Objective To evaluate a laparoscopic technique for insertion of peritoneal catheters in continuous ambulatory peritoneal dialysis (CAPD) patients with the history of lower abdominal surgery orand peritonitis. Methods Between November 2002,and March,2005, the tech- nique was applied in 8 patients (mean age 57.4 years, range 43.6 - 72 years) with end-stage renal disease. During laparoscopic surgery, a 5-mm trocar was placed just below the umbilicus for direct vision and a carbon dioxide pneumoperitoneum was induced up to 14 mmHg. A 5-mm trocar was placed in the standard lower paramedian position on the left side for operation. If there were no adhesion and the Douglas pouch was exposure well, the catheter was advanced into the abdomen under direct vision and guided toward the Douglas pouch through the operation port. If there was adhesion, then another 5-mm trocar was placed in the right lower quadrant and the dissector was placed into the abdominal cavity through this port. With the help of a forceps, the peritoneal catheter. was inserted into the Douglas pouch. The subcutaneous tunnel and the patency test of the catheter was performed as the last main steps in our procedure. Results All procedures were completed laparoscopically. The mean operative time was 30 minutes. There was no intraoperative complication or surgical mortality. One patient developed infection at the catheter exit site 7 days after surgery and was corrected 8 days later. During a mean follow-up time of 11.6 months, all patients went well. Conclusion Laparoscopic technique is feasible, safe, and effective for peritoneal dialysis catheter placements than the traditional method in the patients with previous lower abdominal operation.