手助式腹腔镜肾切除术围手术期并发症的处理

目的探讨手助式腹腔镜肾切除术围手术期并发症的处理方法。方法回顾性分析1998—2004年377例手助式腹腔镜肾切除术患者资料，其中根治性肾切除术206例，单纯性肾切除术91例，根治性肾、输尿管切除术49例，肾部分切除术31例，对围手术期并发症类型、发生率及处理方法进行统计分析。结果377例患者术中估计失血量平均315．6ml（30～7000m1）。术中发生脾脏损伤、难以控制的出血、肠道损伤、肾蒂血管损伤、胰腺损伤等并发症14例（3．7％）。中转开放手术13例（3．4％）。术后发生肠梗阻、肺炎、切口疝、继发性出血、冠心病发作、血管栓塞、低钠血症等并发症48例（12．7％）。死亡2例（0．5％）。有腹腔或腹膜后手术史者围手术期并发症和术式中转率高于无手术史者。结论手助式腹腔镜肾切除术仍会出现一些严重的围手术期并发症。局部粘连、肿瘤体积过大会增加并发症的发生。术中一旦出现严重出血、器官损伤等难以控制的并发症时应及时中转开放手术。充分的术前准备、正确熟练的手术操作可降低并发症的发生率。

Perioperative complications and the treatment in hand-assisted laparoscopic nephrectomy

Objective To evaluate the perioperative complications and the treatment in hand-assis- ted laparoscopic nephrectomy.Methods Hand-assisted laparoscopic nephrectomy was performed in 377 patients,consisting of 206 radical nephrectomies,91 simple nephrectomies,49 radical nephroureterectomies and 31 partial nephrectomies.Results In the 377 patients,the estimated blood loss was 315.6 ml (range,30 -7000 ml).Intraopcrative complications occurred in 14 cases(3.7%),consisting of splenic le- sion,critical bleeding,intestinal injury,renal hilar injury and pancreas injury,etc.Among the 377 cases,lapa- roscopy was converted to open surgery in 13 cases(3.4%)because of intraoperative complication or other difficulties.Postoperative complications occurred in 48 cases( 12.7%),including ileus,aspiration pneumoni- a,incisional hernia,postoperative bleeding,myocardial infarction,vascular thrombosis,hyponatremia.Two pa- tients(0.5%)died.The rates of perioperative complications and conversion to open surgery in patients who had prior abdominal or retroperitoneal surgery were significantly higher than in those who had no prior ab- dominal or retroperitoneal surgery.Conclusions Some serious perioperative complications may occur in hand-assisted laparoscopic nephrectomy.Local adhesion and oversized tumor may increase the morbidity and complication rates.Once critical bleeding or organ injury occurs,hand-assisted laparoscopic procedure should be converted to open surgery.Sufficient preoperative preparations as well as proper and skilled operative ma- nipulation can decrease the incidence of complications.