Hackert T, Kienle P, Weitz J, Werner J, Szabo G, Hagl S, Büchler M W, Schmidt J
Department of Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany.
Surg Endosc. 2003 Oct;17(10):1671-4. doi: 10.1007/s00464-003-9004-1. Epub 2003 Aug 15.
In the early postoperative period after major cardiac surgery using extracorporal circulation, abdominal complications can have serious consequences with a mortality rate of up to 70%. Early diagnosis and the timely institution of therapy are the most important factors to improve the outcome; however, clinical evaluation of the abdomen is difficult in these patients. Diagnostic laparoscopy is a minimally invasive procedure with low procedure-associated morbidity, even in critically ill patients. The aims of our study were to investigate the safety of laparoscopy in critically ill patients suspected to have intraabdominal pathology following cardiac surgery and to evaluate the accuracy of diagnostic laparoscopy compared to laparotomy in this setting.
A total of 17 patients were included (13 male, four female, age 52-80 years) in the early (3-30 days) postoperative period after cardiac surgery using extracorporal circulation (10 ACVB, four valve replacement, one aorto-coronary-venous-bypass (ACVB)+ valve replacement, two cardiac transplantation). Clinical and laboratory findings included distended abdomen (17 of 17), elevated white blood cells (12 of 17), elevated C-reactive protein (CRP) (13 of 17), and elevated lactate levels (11 of 17). The decision to perform laparotomy was taken in all patients on the basis of their clinical condition. Diagnostic laparoscopy was always performed immediately before laparotomy. The laparoscopic findings were then compared to the laparotomy findings.
In one patient, laparoscopy showed no abnormal findings, this was confirmed on laparotomy. Five patients were found to have massive distension of the large bowel without ischemia on both laparoscopy and laparotomy. Colonic ischemia of the right hemicolon was found laparoscopically in six patients, which was confirmed in all cases by open resection and histological workup. Three patients suffered from acute cholecystitis, which was correctly diagnosed by laparoscopy in all cases. In one patient, laparoscopy revealed fibrinous peritonitis without other findings. Open exploration failed to identify the cause of the peritonitis in this patient. Laparoscopy showed no pathological findings in one patient, but laparotomy then revealed necrotizing pancreatitis confined to the lesser sac. There was one laparoscopy-associated intraoperative complication (6%) in this series.
Diagnostic laparoscopy is a minimally invasive procedure that can be performed at low intraoperative risk in critically ill patients and has a high sensitivity (94%) for the correct diagnosis of intraabdominal complications after major cardiac surgery. These results suggest that bedside laparoscopy should be considered for all patients with equivocal abdominal symptoms in this setting.
在体外循环下进行心脏大手术后的早期术后阶段，腹部并发症可能会产生严重后果，死亡率高达70%。早期诊断和及时进行治疗是改善预后的最重要因素；然而，对这些患者进行腹部临床评估很困难。诊断性腹腔镜检查是一种微创手术，即使对于重症患者，其与手术相关的发病率也很低。我们研究的目的是调查腹腔镜检查在怀疑心脏手术后有腹腔内病变的重症患者中的安全性，并评估在这种情况下诊断性腹腔镜检查与剖腹手术相比的准确性。
共有17例患者纳入研究（男性13例，女性4例，年龄52 - 80岁），处于体外循环心脏手术后的早期（3 - 30天）（10例冠状动脉旁路移植术，4例瓣膜置换术，1例冠状动脉旁路移植术 + 瓣膜置换术，2例心脏移植）。临床和实验室检查结果包括腹胀（17例中的17例）、白细胞升高（17例中的12例）、C反应蛋白（CRP）升高（17例中的13例）以及乳酸水平升高（17例中的11例）。所有患者均根据其临床状况决定进行剖腹手术。诊断性腹腔镜检查总是在剖腹手术前立即进行。然后将腹腔镜检查结果与剖腹手术结果进行比较。
1例患者腹腔镜检查未发现异常，剖腹手术证实了这一点。5例患者在腹腔镜检查和剖腹手术中均发现大肠广泛扩张但无缺血。腹腔镜检查发现6例患者右半结肠缺血，所有病例均通过开放切除和组织学检查得到证实。3例患者患有急性胆囊炎，所有病例腹腔镜检查均正确诊断。1例患者腹腔镜检查显示纤维蛋白性腹膜炎，无其他发现。开放探查未能确定该患者腹膜炎的病因。1例患者腹腔镜检查未发现病理结果，但剖腹手术随后发现局限于小网膜囊的坏死性胰腺炎。本系列中有1例与腹腔镜检查相关的术中并发症（6%）。
诊断性腹腔镜检查是一种微创手术，可在重症患者中以较低的术中风险进行，对心脏大手术后腹腔内并发症的正确诊断具有高敏感性（94%）。这些结果表明，对于这种情况下有可疑腹部症状的所有患者，应考虑床边腹腔镜检查。
