Barbera L, Ludemann R, Grossefeld M, Welch L, Mumme A, Swanstrom L
Department of Surgery, St. Josef Hospital, Ruhr University, Bochum, Germany.
Surg Endosc. 2000 Jan;14(1):63-6. doi: 10.1007/s004649900013.
Recent clinical studies have demonstrated the feasibility of laparoscopic surgery for aortic occlusive and aneurysmal disease. However, transperitoneal aortic access is compromised by poor exposure in the operative field from uncontrolled bowel. The retractors that are currently available are inadequate for this task. The development of new retractors would help to facilitate laparoscopic aortic surgery.
Six female piglets (28-30 kg) in each group underwent laparoscopy with pneumoperitoneum (12 mmHg). Exposure of the infrarenal aorta and cross-clamping were undertaken through a transperitoneal approach. Two paddles inserted in a polyester bilayer (mobile device, group A) or a mesh net fixed to the abdominal wall (fixed device, group B) were used to retain the bowel. Aortotomy and suturing were performed to mimic a vascular procedure. After bleeding was controlled, the intraabdominal pressure (IAP) was lowered to 6 mmHg, and retraction was assessed for 30 min. The main outcome measures were time to deploy the retractors, time to perform the vascular procedure, time to withdraw the devices, and total procedural time. Blood loss and frequency of retraction failure were also recorded.
Mean time to deploy the device was 22 +/- 12 min in group A and 36 +/- 34 min in group B (n.s.). Vascular surgery time averaged 60 +/- 24 min in group A and 68 +/- 16 min in group B (n.s.). The times to withdraw the nets were 3.6 +/- 1.2 min and 13.5 +/- 8.2 min, respectively (p < 0.05). Total surgery time was 155 +/- 41 min vs 174 +/- 49 min (n.s.). There were six retraction failures, five in group A and one in group B. When lower IAP was used, there was only one failure in each study group. Mean blood loss was <150 ml in both groups. There were no major complications.
Both methods provided adequate exposure of the infrarenal aorta. Vascular surgery time and blood loss were similar for both groups. The movable device proved more usable and, at lower IAP, more effective. The results of this study demonstrate effective bowel retraction for laparoscopic aortic surgery.
近期临床研究已证实腹腔镜手术治疗主动脉闭塞性疾病和动脉瘤性疾病的可行性。然而，经腹主动脉入路因肠道不受控制而导致手术视野暴露不佳。目前可用的牵开器不足以完成这项任务。新型牵开器的研发将有助于促进腹腔镜主动脉手术。
每组6只雌性仔猪（28 - 30千克）接受气腹（12毫米汞柱）腹腔镜检查。通过经腹途径暴露肾下腹主动脉并进行交叉钳夹。使用插入聚酯双层的两个挡板（移动装置，A组）或固定在腹壁的网状物（固定装置，B组）来固定肠道。进行主动脉切开和缝合以模拟血管手术。出血得到控制后，将腹内压（IAP）降至6毫米汞柱，并评估牵开30分钟。主要观察指标为部署牵开器的时间、进行血管手术的时间、取出装置的时间和总手术时间。还记录了失血量和牵开失败的频率。
A组部署装置的平均时间为22±12分钟，B组为36±34分钟（无显著差异）。A组血管手术时间平均为60±24分钟，B组为68±16分钟（无显著差异）。取出网状物的时间分别为3.6±1.2分钟和13.5±8.2分钟（p < 0.05）。总手术时间为155±41分钟对174±49分钟（无显著差异）。有6次牵开失败，A组5次，B组1次。使用较低IAP时，每个研究组仅有1次失败。两组平均失血量均<150毫升。无重大并发症。
两种方法均能充分暴露肾下腹主动脉。两组的血管手术时间和失血量相似。移动装置证明更易于使用，且在较低IAP时更有效。本研究结果表明腹腔镜主动脉手术中肠道牵开有效。
