Hannon J K, Faircloth W B, Lane D R, Ronderos J F, Snow L L, Weinstein L S, West Iii J L
Department of Surgery, Mobile Infirmary Medical Center, Mobile, AL 36660, USA, USA.
Surg Endosc. 2000 Mar;14(3):300-304. doi: 10.1007/s004640000070.
Laparoscopic transperitoneal fusion of the L5-S1 spinal interspace has become a common procedure. Retroperitoneal retraction and laparoscopic instrumentation without insufflation also allows visualization of the upper lumbar spaces, but this procedure is much more difficult to accomplish. We review and compare our results using each of these techniques for the treatment of mechanical instability and chronic back pain. A total of 35 selected patients underwent intervertebral fusion between February 1996 and August 1998. Their mean age was 48 years. There were 22 female and 13 male patients. Standard CO insufflation was used in 10 patients with L5-S1 fusions. Retractional gasless technique was used in nine patients with fusions at L5-S1, 16 patients at L4-L5, one patient at L3-L4, three patients at L2-3, and one patient at L1-L2. Thus, we performed a total of 40 lumbar fusions in 35 patients. In the 19 patients with the gasless technique, a balloon dissector and retractor facilitated the retroperitoneal exposure. Seven of these 19 patients were converted to open procedures, most commonly due to lacerations of the peritoneal lining that prohibited visualization. None of the L5-S1 patients with insufflation were converted to open. Mean operative time in the insufflated patients was 152 min vs 181 min for the retractional technique. There were seven complications in the transperitoneal group: one fusion device migration, one postoperative UTI, one intracerebral hemorrhage, one severe postoperative pancreatitis, and three iliac vein lacerations. There were 16 complications in the retroperitoneal group: one deep vein thromboses, one serosal bowel injury, one small tear in the spleen, one cage migration, one postoperative pulmonary atelectasis, one postoperative hydrocele, four postoperative ileus, and six peritoneal tears. The mean postoperative stay was three days for both groups. There were no deaths. The L5-S1 interspace is best approached transperitoneally for anterior fusion. Although the retroperitoneal retractional technique is much more difficult and has a longer and steeper learning curve, it does allow laparoscopic anterior fusion of the upper lumbar spine.
腹腔镜下经腹膜腔进行L5 - S1椎间融合术已成为一种常见手术。腹膜后牵拉及无气腹腹腔镜器械操作也能对上腰椎间隙进行可视化观察，但该手术实施起来要困难得多。我们回顾并比较了运用这两种技术治疗机械性不稳和慢性背痛的结果。1996年2月至1998年8月期间，共有35例选定患者接受了椎间融合术。他们的平均年龄为48岁。其中女性患者22例，男性患者13例。10例L5 - S1融合患者采用标准二氧化碳气腹法。9例L5 - S1融合患者、16例L4 - L5融合患者、1例L3 - L4融合患者、3例L2 - 3融合患者及1例L1 - L2融合患者采用牵拉式无气腹技术。因此，我们在35例患者中总共进行了40例腰椎融合术。在采用无气腹技术的19例患者中，球囊剥离器和牵开器有助于腹膜后暴露。这19例患者中有7例转为开放手术，最常见的原因是腹膜内衬撕裂导致无法进行可视化观察。采用气腹法的L5 - S1患者均未转为开放手术。气腹组患者的平均手术时间为152分钟，而牵拉技术组为181分钟。经腹膜腔组有7例并发症：1例融合装置移位、1例术后尿路感染、1例脑出血、1例严重术后胰腺炎及3例髂静脉撕裂。腹膜后组有16例并发症：1例深静脉血栓形成、1例浆膜性肠损伤、1例脾脏小撕裂、1例椎间融合器移位、1例术后肺不张、1例术后鞘膜积液、4例术后肠梗阻及6例腹膜撕裂。两组患者的平均术后住院时间均为3天。无死亡病例。对于前路融合术，L5 - S1间隙经腹膜腔途径最佳。尽管腹膜后牵拉技术困难得多，学习曲线更长且更陡，但它确实能实现上腰椎的腹腔镜前路融合。
