完全乳晕入路腔镜甲状腺切除术隧道出血的分析与处理

摘要

目的：探讨完全乳晕入路腔镜甲状腺切除术隧道出血的部位及处理方法。方法回顾分析2005年6月～2014年3月行完全乳晕入路腔镜甲状腺切除术1080例中发生的由穿刺套管在穿刺过程中致皮下穿刺隧道活动性出血的37例临床资料，包括出血隧道、出血部位、手术时间、术中出血量、术后引流量、术后住院时间、术后并发症。结果隧道出血发生率3．4％（37／1080），其中观察隧道出血发生率2．7％（29／1080），明显高于主操作隧道0．2％（2／1080）及辅操作隧道0．6％（6／1080）（χ2＝34．830，P＝0．000）。中段出血发生率2．9％（31／1080），明显高于外口0．5％（5／1080）及内口0．1％（1／1080）（χ2＝43．524，P＝0．000）。37例均术中成功处理隧道出血，无术后再出血。手术时间（112．6±17．5）min，术中出血量（22．5±9．6）ml，术后2天引流量（91．2±17．9）ml，术后住院时间（3．8±1．5）d。3例术后局部皮肤瘀斑、1例皮下积液，对症治疗治愈。结论出血多发生于观察隧道及隧道中段。隧道外口出血采用超声刀凝血，隧道中段及内口出血采用经皮缝扎压迫止血，效果良好。%Objective To analyze and explore the management for tunnel bleeding during endoscopic thyroidectomy via complete areola approach . Methods A retrospective analysis was made on clinical data of 37 patients suffering tunnel bleeding caused by trocars during puncture out of 1080 cases of endoscopic thyroidectomy via complete areola approach from June 2005 to March 2014.Parameters reviewed included bleeding tunnel , bleeding site, operative time, operative blood loss, postoperative drainage, postoperative hospital stay , and postoperative complications . Results The total incidence of tunnel bleeding was 3.4%(37/1080).Hereinto, the incidence of bleeding in observation tunnel was 2.7%(29/1080), which was significantly higher than that in the main operating tunnel (0.2%, 2/1080) and the auxiliary operating tunnel (0.6%, 6/1080) (χ2 =34.830, P=0.000).The incidence of bleeding in the middle part of the tunnel was 2.9% (31/1080), which was significantly higher than that at the exterior edge (0.5%, 5/1080) and the inner edge (0.1%, 1/1080) (χ2 =43.524, P=0.000).The tunnel bleeding was successfully treated in 37 cases without postoperative bleeding .The mean operating time was 112.6 ±17.5 min;the mean intraoperative blood loss was 22.5 ±9.6 ml;the mean drainage volume after 2 postoperative days was 91.2 ±17.9 ml;the mean postoperative hospital stay was 3.8 ±1.5 d.Local skin ecchymosis occurred in 3 cases and subcutaneous hydrops occurred in 1 case postoperatively , which were recovered after symptomatic treatment . Conclusions Bleeding often occurs in observation tunnel and the middle part of the tunnel . It is effective to treat bleeding at the exterior edge by using harmonic scalpel , and in the middle part of the tunnel and at the inner edge by using percutaneous suturing .