免气腹腹腔镜新生儿巨结肠根治术的临床体会

摘要

目的:总结免气腹腹腔镜新生儿巨结肠根治术的应用优势.方法:回顾分析2005年至今为41例新生儿行巨结肠根治术的临床资料,患者根椐手术方式分为3组,2005年7月至2008年12月12例行单纯经肛门Soave术(单纯组),2009年1月至2011年2月行气腹腹腔镜辅助下经肛门Soave术16例(气腹组),2011年3月至今行免气腹腹腔镜辅助下经肛门Soave术13例(免气腹组),对比分析3组手术结果.结果:腹腔镜手术均获成功,无一例中转开腹.单纯组中4例加用腹腔镜辅助完成手术.3组患儿术中出血量、术后肛门排气时间、住院时间差异无统计学意义,无一例发生吻合口漏.单纯组手术时间明显长于其他两组,差异有统计学意义(P＜0.05)；单纯组、免气腹组拔管时间明显短于气腹组,术后患儿清醒快,差异有统计学意义(P＜0.05).单纯组、免气腹组患儿血液动力学指标在不同时段有波动,但差异无统计学意义(P＞0.05).气腹组患儿术中、术后血液动力学指标波动较明显,差异有统计学意义(P＜0.05).患儿均于术后第20天开始扩肛,每天一次,连续3个月,无一例发生肛门狭窄.术后随访4～28个月,气腹组与免气腹组患儿于术后4～6个月肛门排便基本正常；术后24个月,单纯组中尚有3例患儿有污粪现象.结论:免气腹腹腔镜辅助新生儿巨结肠根治术安全可行、操作简便、微创美容、经济实用,避免了腹内高压对血流动力学参数的影响,值得临床推广.%Objective:To summarize the advantages of gasless laparoscopic radical procedure for Hirschsprung disease in newborns.Methods:The clinical data of 41 newborns who suffered from Hirschsprung disease and underwent endorectal Soave procedure from 2005 were retrospectively analyzed.The 41 cases were assigned to 3 groups according to the operative method:simple group (simple endorectal Soave operation,12 cases,from Jul.2005 to Dec.2008),pneumoperitoneum group (pneumoperitoneum laparoscopic assisted endorectal Soave operation,16 cases,from Jan.2009 to Feb.2011),and gasless group (gasless laparoscopic assisted endorectal Soave operation,13 cases,from Mar.2011 till now).The clinical results were comparatively studied.Results:All laparoscopic operations were successful without conversion to laparotomy.4 operations of simple group were assisted by laparoscopy.There were no singificant differences among.3 groups in inrtaoperative blood loss,time of postoperative passage o gas by anus and hospital stay.No anastomotic leakage was found.Operative time of simple group was longer than that of the other groups(P ＜ 0.05).Time of tube removal in simple group and gasless group was shorter than that in pneumoperitoneum group,children awaked more quickly (P ＜ 0.05).Hemodynamics indexes of simple group and gasless group changed in different phase,but the differences were not significant(P ＞0.05).Intraoperative and postoperative hemodynamics indexes of pneumoperitoneum group boviously changed (P ＜ 0.05).One tim of anal dilatation per day was performed for all the chidren 20 d after operation for 3 months,no anal stenosis occurred.Children were followed up for 4-28 months,defecation of pneumoperitoneum group and gasless group was basically normal 4-6 months after operation.In simple group,3 patients still suffered from fecal soiling 24 months after operation.Conclusions:Gasless laparoscopic-assisted endorectal Soave procedure for Hirschsprung disease in newborns is safe,feasible,easy,mini-invasive,cosmetic,economical and practical.It avoids the influences of high pneumoperitoneum pressure to hemodynamics,and is worth spreading in clinical practices.