目的探討腹腔鏡技術在治療外傷性脾破裂中的可行性和安全性。 方法回顧性分析筆者所在醫院2012年3月至2014年3月期間應用腹腔鏡技術救治的19例外傷性脾破裂患者的臨床資料。 結果本組19例患者中，順利完成腹腔鏡手術17例，中轉開腹2例，均獲得成功救治，痊愈出院。其中行腹腔鏡下電凝止血＋生物蛋白膠黏合保脾4例，行腹腔鏡下無損傷線縫合＋網膜覆蓋保脾8例，行腹腔鏡脾切除術5例，中轉開腹行脾切除術2例。手術時間50～186 min，平均90 min；術中失血250～2 200 mL，平均780 mL；術后住院時間7～26 d，平均13.5 d，術后均無并發癥發生。術后19例患者均獲訪，隨訪時間為3～12個月，平均8個月。隨訪期間無死亡及遠期并發癥發生。 結論對外傷性脾破裂患者選擇性施行的腹腔鏡脾修補術和脾切除術具有良好的效果，其具有創傷小、痛苦輕及恢復快的優點，安全而可行，值得推廣。
【Abstract】Objective To evaluate the operation of laparoscopic splenectomy（LS）, its safety and clinical effects.Methods Literature of the advances of LS were reviewed and analyzed.Results With the development of technology and surgical technique, the indications for LS were widened, the size of spleen plays an important role in the clinical outcome of LS.Conclusion LS has all the advantages of minimally invasive surgery. The application of handassisted technique is safe and feasible for giant spleen. With the accumulation of surgical experiences and technique development, LS will be extensively used in clinic.
目的 探討血吸蟲病性肝硬變行脾切除術后再發大出血的外科治療方法。 方法 回顧性分析1987年4月至1999年12月期間我院收治的經左胸行賁門周圍血管離斷術治療脾切除術后再發大出血11例患者的臨床資料。結果 急診手術4例，2例死亡，其中1例手術后30 d死于肝功能衰竭，另1例于出院后2個月再發大出血而死亡。余2例及擇期手術7例均無手術并發癥和死亡率，隨訪6~8年，無出血再發。結論 對脾切除術后再發大出血病例行斷流術，經左胸入路是一種可取的治療方法。
ObjectiveTo evaluate the operative technique and clinical efficacy of laparoscopic splenectomy (LS) combined with esophagogastric devascularization in treatment of portal hypertension induced by liver cirrhosis. MethodsTwelve cases with esophageal and gastric varices induced by portal hypertension and liver cirrhosis were treated by the LS combined with esophagogastric devascularization in our department from March 2009 to August 2010, which clinical data were analyzed and summarized retrospectively. ResultsThe splenic artery was ligated before the treatment of splenic pedicle in 12 cases, LS combined with pericardial devascularization was successfully performed in 10 cases, 7 cases of which were treated by the level two transection method of splenic pedicle, and 2 cases were converted to open surgery due to intraoperative bleeding. In 10 cases, the operative time was 180-300 min (average 210 min), and intraoperative blood loss was 200-1 000 ml (average 480 ml). The postoperative hospital stay was 8-15 d (average 9 d)， the postoperative complications included plural effusion （lt;300 ml） in 2 cases， mild ascites （lt;300 ml） in 2 cases, and mild pancreatic leakage in 1 case， but all were cured eventually， and no mortality occurred. Followup was conducted in 12 patients for 4 to 20 months (average 7 months), and no rebleeding occurred. ConclusionsLS combined with pericardial devascularization is relatively safe and effective methods in treatment of portal hypertension induced by liver cirrhosis. The keys to success include ligation of splenic artery, and the use of harmonic scalpel combined with ligasure to treat splenic pedicle.
Objective To discuss surgical skills and clinical value of laparoscopic splenectomy with behind splenic hilus tunnel-building technique. Method The clinical data of 1 patient with HBV-related hepatic cirrhosis combined splenomegaly and hypersplenism treated in the Second Affiliated Hospital of Chongqing Medical University was discussed and summarized. Results The patient underwent the laparoscopic splenectomy with surgical approach of from bottom to top, front to back, and shallow to deep. The key point of the tunnel-building technique was fully exposed the upper and lower poles of the splenic pedicle. The operative time was 70 min, the intraoperative blood loss was 50 mL, and the discharge time was 5 d after operation. Conclusion Laparoscopic splenectomy with behind splenic hilum tunnel-building technique is safe and feasible, especially for beginners.
Objective To explore the cause, diagnosis, and treatment methods of portal vein thrombosis （PVT） after splenectomy. Methods The clinical data of 29 patients who were got splenectomy because of portal hypertension or traumatic splenic rupture from August 2002 to August 2008 in our hospital were analyzed retrospectively. Results Tweenty-seven patients with PVT were treated successfully, whose thrombi were absorbed completely or partially. One case died of peritonitis，septic shock，and multiple organ failure. One case died of hematemesis, hepatic coma，and multiple organ failure. Tweenty-four patients were followed up, the follow-up time was 0.5 to 3 years, the average was 2 years. Two cases died of massive hemorrhage, 1 case died of hepatic encephalopathy，and 1 case died of liver failure. Two cases occurred deep venous thrombosis in one year after treatment, and the remaining patients had no recurrence of venous thrombosis. Conclusions PVT have some connection with the raise of blood platelet and the hemodynamic changes of the portal vein system after splenectomy. Standardization of operation, early diagnosis, early line anticoagulant，and antiplatelet adhesion therapy are effective way to prevent and treat PVT.
目的 探討腹腔鏡下脾切除術（LS）治療特發性血小板減少性紫癜(ITP)的臨床效果。方法 我院2003年1月至2008年8月期間行LS治療ITP患者20例，將術前與術后1、2、7、14、30、90及180 d的血小板計數進行比較。結果 20例ITP患者均順利完成LS，平均手術時間為156 min，術中出血平均50 ml，平均住院時間為9 d。完全停用藥物14例； 4例患者術后需繼續服用激素治療，但激素用量較前明顯減少； 無效2例。總有效率為90%。術后1、2、7、14、30、90及180 d的血小板數量分別為(251.6±91.4)×109/L、(312.6±90.1)×109/L、(343.2±103.7)×109/L、(300.0±98.2)×109/L、(175.6±42.6)×109/L、(151.8±42.1)×109/L及(207.0±53.4)×109/L,分別與術前〔(38.3±19.4)×109/L〕比較，經t檢驗，差異均有統計學意義（P＜0.001）。結論 LS治療ITP是可行和安全的，手術效果滿意。
Objective To explore the methods， clinical effects， and application value of laparoscopic splenectomy combined with pericardial devascularization. Methods The clinical data of 23 patients with liver cirrhosis and portal hypertension who performed laparoscopic splenectomy combined with pericardial devascularization between july 2009 and july 2012 in our hospital were analyzed retrospectivly. Results In 23 cases， 2 cases were converted laparotomy due to bleeding， 21 cases were successfully performed laparoscopic splenectomy combined with pericardial devascularization. The operative time was 230-380 minutes （average 290 minutes）. The intraoperative blood loss was 300-1 500 mL （average 620 mL）. The postoperative fasting time was 1-3 days （average 2 days）. The postoperative hospital stay was 8-14 days （average 10 days）. Conclusion Laparoscopic splenectomy combined with pericardial devascularization is a feasible， effective， and safe procedure as well as minimally invasive hence is applicable for patients with portal hypertension and hypersplenism．