Wang Yi-Zarn
Louisiana State University Health Sciences Center, Department of Surgery, Section of Surgical Oncology and Endocrine Surgery, New Orleans, Louisiana, USA.
JSLS. 2009 Oct-Dec;13(4):560-3. doi: 10.4293/108680809X12589998404443.
An open, second-look laparotomy often is required to assess ischemic bowel after extensive mesenteric lymphadenectomy to cytoreduce midgut carcinoids. Aggressive resection of tumor at the base of the mesentery may compromise the integrity of the blood supply to the involved segment of intestine. Long segments of bowel that initially appear ischemic are sometimes created. The surgeon is faced with the decision to perform a resection or to close the abdomen temporarily knowing that this patient will require a second-look laparotomy.
Segments of bowel showing signs of possible ischemia were preserved based on signs of perfusion. A side-side anastomosis was performed in the standard fashion. A Jackson Pratt drain was placed in an area adjacent to the anastomosis and brought out through the abdominal wall, and the incision was closed. Forty-eight hours later, a laparoscopic second-look operation was performed. A pneumoperitoneum was established using the drain tubing as the CO(2) inflation port. The drain was removed, and a 5-mm trocar was inserted into the abdomen via its tract. Segments of previously questionable dusky bowel and the anastomosis were inspected with a laparoscope.
Our 3 second-look operations were completed in approximately 5 minutes, and the patients recovered without complication or prolonged hospital course. Our fourth patient progressed extremely well postoperatively and was able to avoid the planned second-look laparoscopy.
This technique provides an easy solution for the intraoperative finding of questionable blood supply in the intestines.
广泛肠系膜淋巴结清扫以减灭中肠类癌后，常需进行开放性二次剖腹探查以评估肠缺血情况。在肠系膜根部积极切除肿瘤可能会损害受累肠段血供的完整性。有时会造成起初看似缺血的长段肠管。外科医生面临着这样的抉择：是进行切除术还是暂时关闭腹腔，因为他们知道该患者需要二次剖腹探查。
根据灌注迹象保留显示可能缺血迹象的肠段。以标准方式进行侧侧吻合。在吻合口附近区域放置一根杰克逊·普拉特引流管，并引出腹壁，然后关闭切口。48小时后，进行腹腔镜二次探查手术。利用引流管作为二氧化碳充气端口建立气腹。拔除引流管，通过其通道插入一个5毫米的套管针进入腹腔。用腹腔镜检查先前有疑问的暗红色肠段和吻合口。
我们的3例二次探查手术在大约5分钟内完成，患者恢复良好，无并发症，住院时间未延长。我们的第四例患者术后恢复极佳，能够避免计划中的二次腹腔镜探查。
该技术为术中发现可疑的肠血供问题提供了一个简便的解决方案。
