Shamiyeh Andreas, Glaser Karl, Kratochwill Heinz, Hörmandinger Karl, Fellner Franz, Wayand Wolfgang U, Zehetner Jörg
II. Surgical Department, Ludwig Boltzmann Institute for Operative Laparoscopy, AKH Linz, Krankenhausstrasse 9, Linz 4020, Austria.
Surg Endosc. 2009 Feb;23(2):313-7. doi: 10.1007/s00464-008-9920-1. Epub 2008 Apr 29.
In laparoscopy, 50% of all complications occur during establishment of the pneumoperitoneum. Elevation of the fascia is recommended for the Veress needle approach, although the benefit has not been proved to date. This study aimed to evaluate the intraabdominal changes during lifting of the fascia with regard to the distance from the fascia to the retroperitoneal vessels and the intestine for access in laparoscopy.
For 10 patients scheduled to undergo laparoscopic cholecystectomy, the operation started with the computed tomography (CT) scan. After orotracheal intubation, a CT scan of the umbilical region was performed. After a supraumbilical incision, the fascia was freed and elevated with stay sutures. During maximal elevation, a second CT scan was performed. Distances to the intestinal (small bowel) and retroperitoneal structures (iliac artery, vena cava) were measured. Intraabdominal pressure was measured with a transcystic balloon manometer before (a) and after (b) elevation of the fascia, after insertion of the Veress needle (c), and after completion of the insufflations (d).
Lifting of the fascia increased the distance between the fascia and the intestinal structures in the patients with no prior abdominal surgery (mean distance, 1.92 cm; range, 0.87-2.67 cm) and the distance between the fascia and the retroperitoneal vessels (mean distance, 7.83 cm; range, 3-11 cm). The median intraabdominal pressures in terms of cm H(2)O were 5.4 for a, 1.1 for b, 1.1 for c, and 12. 5 for d.
Elevation of the fascia before the first entrance to the abdominal cavity for laparoscopy may increase safety due to a significant enlargement of distance between the fascia and the retroperitoneal structures.
在腹腔镜手术中，所有并发症的50%发生在气腹建立过程中。尽管目前尚未证实其益处，但对于Veress针穿刺法，建议抬高筋膜。本研究旨在评估抬高筋膜时腹腔内的变化，包括筋膜与腹膜后血管及肠管的距离，以便在腹腔镜手术中进行操作。
对于10例计划行腹腔镜胆囊切除术的患者，手术开始时进行计算机断层扫描（CT）。经口气管插管后，对脐区进行CT扫描。在脐上做切口后，用缝线游离并抬高筋膜。在最大抬高时，进行第二次CT扫描。测量与肠管（小肠）和腹膜后结构（髂动脉、腔静脉）的距离。在抬高筋膜前（a）、抬高后（b）、插入Veress针后（c）和充气完成后（d），用经膀胱球囊压力计测量腹腔内压力。
对于无腹部手术史的患者，抬高筋膜增加了筋膜与肠管结构之间的距离（平均距离1.92 cm；范围0.87 - 2.67 cm）以及筋膜与腹膜后血管之间的距离（平均距离7.83 cm；范围3 - 11 cm）。以厘米水柱为单位的腹腔内压力中位数，a为5.4，b为1.1，c为1.1，d为12.5。
在腹腔镜手术首次进入腹腔前抬高筋膜，可能因筋膜与腹膜后结构之间距离显著增大而提高安全性。
