Saito Kazutomo, Toyama Hiroaki, Saito Moeka, Yamauchi Masanori
Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, 2-1 Seiryomachi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan.
Department of Anesthesiology, Tohoku University Hospital, 1-1 Seiryomachi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan.
JA Clin Rep. 2021 Jul 13;7(1):56. doi: 10.1186/s40981-021-00456-6.
Laparoscopic surgery for a patient with Fontan physiology is challenging because pneumoperitoneum and positive pressure ventilation could decrease venous return and the accumulated partial pressure of arterial carbon dioxide (PaCO) could increase pulmonary vascular resistance, which might lead to disruption of the hemodynamics.
A 25-year-old man with Fontan physiology was scheduled to undergo laparoscopic liver resection for Fontan-associated liver disease (FALD) with noninvasive monitoring of cardiac output (CO) by transpulmonary thermodilution in addition to transesophageal echocardiography. The abdominal air pressure was maintained low, and we planned to switch to open abdominal surgery promptly if hemodynamic instability became apparent because of the accumulated PaCO or postural change. Consequently, the pneumoperitoneum had limited influence on circulatory dynamics, but central venous pressure significantly decreased with postural change to the reverse Trendelenburg position. Laparoscopic liver resection for FALD was performed successfully with no significant changes in CO and central venous saturation.
With strict circulation management, laparoscopic surgery for a patient with Fontan physiology can be performed safely. Comprehensive hemodynamic assessment by noninvasive transpulmonary thermodilution can provide valuable information to determine the time for shift to open abdominal surgery.
对于患有Fontan循环生理的患者，腹腔镜手术具有挑战性，因为气腹和正压通气会降低静脉回流，而动脉血二氧化碳分压（PaCO）的累积可能会增加肺血管阻力，这可能导致血流动力学紊乱。
一名患有Fontan循环生理的25岁男性计划接受腹腔镜肝切除术，以治疗Fontan相关肝病（FALD），除经食管超声心动图外，还通过经肺热稀释法对心输出量（CO）进行无创监测。腹部气压保持在较低水平，如果因PaCO累积或体位改变出现血流动力学不稳定，我们计划立即转为开腹手术。因此，气腹对循环动力学的影响有限，但转为头低脚高位时中心静脉压显著降低。成功实施了FALD的腹腔镜肝切除术，CO和中心静脉血氧饱和度无明显变化。
通过严格的循环管理，可为患有Fontan循环生理的患者安全实施腹腔镜手术。通过无创经肺热稀释法进行全面的血流动力学评估可为确定转为开腹手术的时机提供有价值的信息。
