Woolcott R
Newcastle Obstetrics and Gynaecological Society, New South Wales, Australia.
Aust N Z J Obstet Gynaecol. 1997 May;37(2):216-9. doi: 10.1111/j.1479-828x.1997.tb02257.x.
The records of 6,173 laparoscopies performed by specialist gynaecologists in the course of routine gynaecological care using the technique of direct insertion of the umbilical trocar and insufflation of carbon dioxide under vision were reviewed to ascertain the incidence of serious complications. A review of the published literature on laparoscopy methodology was also undertaken to complement the data obtained from this study. The nature of the records precluded accurate assessment of both indications and minor complications. There were 4 perforating bowel injuries (0.06%) requiring laparotomy (s small intestine, 2 large intestine). There were no cases of major vascular injury or gas embolus necessitating surgical or resuscitative measures. On 3 of the 4 occasions where bowel injury occurred the patients had undergone prior abdominal surgery and had midline vertical subumbilical incisions. Review of the published literature demonstrated bowel or vessel perforation rates (requiring laparotomy or resuscitation) of 1 in 1,000 regardless of whether the method of gaining peritoneal access was open (Hasson) technique, Verres needle insufflation, or direct trocar. Direct trocar insertion may reduce the risk of gas embolism by insufflating only after intraperitoneal replacement has been confirmed, moreover it allows immediate recognition and rapid treatment of major blood vessel laceration, both of which have been identified as being crucial in reducing laparoscopy associated mortality. When compared to other available methods of gaining peritoneal access for laparoscopy, direct trocar insertion followed by insufflation of carbon dioxide under vision can be performed with the same degree of safety for the patient. It is simply wrong to deduce from the available data that one particular technique of gaining peritoneal access is superior to another. Each have their individual advantages and disadvantages and similar morbidity when performed by experienced operators with appropriate indications. In light of this observation, each alternative should be considered by the individual surgeon to assess which would best suit his or her operating technique and the particular circumstance of each patient. Indeed preference should be given to the method with which the surgeon is most comfortable or with which he or she has the most experience.
回顾了6173例由妇科专家在常规妇科护理过程中使用脐部套管针直接插入技术并在直视下注入二氧化碳进行的腹腔镜检查记录，以确定严重并发症的发生率。还对已发表的关于腹腔镜检查方法的文献进行了综述，以补充本研究获得的数据。记录的性质妨碍了对适应症和轻微并发症的准确评估。有4例肠穿孔损伤（0.06%）需要开腹手术（2例小肠，2例大肠）。没有发生需要手术或复苏措施的重大血管损伤或气体栓塞病例。在发生肠损伤的4例病例中，有3例患者此前接受过腹部手术，并有脐下正中垂直切口。对已发表文献的回顾表明，无论获得腹膜腔进入的方法是开放（哈森）技术、韦雷斯针注入法还是直接套管针插入法，肠或血管穿孔率（需要开腹手术或复苏）均为千分之一。直接套管针插入法可通过仅在确认腹腔内复位后注入气体来降低气体栓塞的风险，此外，它还能立即识别并快速治疗主要血管撕裂伤，这两者都被认为对降低腹腔镜检查相关死亡率至关重要。与其他可用的腹腔镜检查获得腹膜腔进入的方法相比，直接套管针插入法然后在直视下注入二氧化碳对患者来说具有相同程度的安全性。从现有数据推断一种特定的获得腹膜腔进入的技术优于另一种技术是完全错误的。每种方法都有其各自的优缺点，并且由有经验的操作者在适当适应症下进行操作时发病率相似。鉴于此观察结果，每位外科医生应考虑每种替代方法，以评估哪种最适合其手术技术和每位患者的具体情况。实际上，应优先选择外科医生最熟悉或经验最丰富的方法。
