【作者】 郭景阳；

【导师】 杨文增；

【作者基本信息】 河北大学 ， 外科学， 2011， 硕士

【摘要】 目的通过探讨后腹腔镜手术时CO2气腹压力及CO2气体吸收对机体血流动力学、肝肾功能、凝血、内分泌等方面的影响,客观评价经腹膜后途径手术的优越性,为临床上选择此种技术提供理论依据；通过检测手术患者术中及术后各种指标的变化,进一步评价经腹膜后途径手术的安全性及存在的风险,为临床上能够及时发现各种异常,帮助患者平稳渡过围手术期提供客观的理论依据。方法选择河北大学附属医院2009年7月份到2010年11月份住院行后腹腔镜手术患者60例(其中内分泌指标检测组选用38例,及本组病例除外肾上腺疾病组),所有患者均符合入选标准,术中应用CO2气腹机持续高流量灌注CO2气体以维持操作空间,气腹压维持在14mmHg,手术时间为60-240分钟,平均150分钟,分别于手术前(T1),手术完毕时(T2),术后第1天(T3),术后第2天(T4),术后第3天(T5),分别记录患者：1.尿量；2.肾功能如：血肌酐、尿素氮、尿量、二氧化碳结合力(CO2CP)等；3.肝功,如：天门冬氨酸氨基转移酶、丙氨酸氨基转移酶、总胆红素等；4.凝血功能,如：凝血酶原时间、凝血酶时间比值、活化部分凝血活没时间、纤维蛋白原、凝血酶时间、D-二聚体等；5.血流动力学,如：血压、心率；6.内分泌,如肾素、血管紧张素、醛固酮、皮质醇等；6.血气分析,如：PH值、HCO3-。所有数据均应用重复测量数据的方差分析,两两比较应用LSD t检验,P<0.05为有统计学意义。结果不同时间段的心率未见显著性差异(P>0.05),收缩压及舒张压不同时间段未见显著性差异(P>0.05),不同时间段尿量变化T4、T5少于T1、T2,有显著性差异(P<0.05)；血肌酐及尿素氮不同时间段变化无显著性差异(P>0.05),肾切除组手术前后血肌酐及尿素氮变化无显著性差异(P>0.05),二氧化碳结合力T2较T1变化明显,有显著性差异(P<0.05),术后第二天逐渐恢复正常,T5与T1比较,无显著性差异(P>0.05)；天门冬氨酸氨基转移酶、丙氨酸氨基转移酶的变化无显著性差异(P>0.05),总胆红素T3、T4明显高于T1,有显著性差异(P<0.05)；凝血功能如：凝血酶原时间、纤维蛋白原、D-二聚体等。D-二聚体及凝血酶原时间术前与术后相比有显著性差异(P<0.05),纤维蛋白原手术前后相比无统计学意义；血气分析,如：PH值、HCO3-等T2、T3较T1变化有显著性差异(P<0.05),但均在正常参考值范围,术后第2天逐渐恢复正常；内分泌如肾素、血管紧张素、醛固酮变化T4较T1变化有显著性差异(P<0.05),皮质醇则无显著性差异(P>0.05)。结论1.侧卧位腰部抬高体位下的腹膜后CO2气腹对机体肝、肾功能影响较小,对于实施肾切除患者亦无较大影响,实施同种手术时,宜选择经腹膜后途径；2.后腹腔镜手术对机体凝血机制影响显著,术后需应用气压治疗并鼓励患者早日下床活动,防止下肢静脉血栓形成及相应的肺栓塞、脑栓塞并发症；3.CO2气体吸收可导致PH降低、HCO3-等的变化,与术后尿量减少造成的代谢产物体内淤积可能互为因果,进一步加重术后患者酸中毒,因此,术后应常规补液至少3000ml以上,防止尿量的明显减少,并适当应用抗氧化及减少自由基损害的药物；4.CO2CP是一定温度及压力下血浆中HCO3-与CO2结合的多少,其水平反映体内CO2的量,此研究表明,术后患者血CO2CP水平明显高于术前,因CO2的调节主要靠肺进行,因此实施腹腔镜手术前患者均需做肺功能检查,对于异常患者应给予积极的纠正,待肺功能恢复或接近正常后再行手术,如肺功能受损严重、无法改善者则宜选择开放手术较为安全；5.后腹腔镜手术对皮质醇变化影响较小说明后腹腔镜手术对机体的刺激及干扰较小,没有引起明显的应激激素的释放,但术中对肾动静脉刺激造成肾素的释放增加,肾素-血管紧张素-醛固酮轴激活可参与尿量减少的机制中,因此围手术期应用小剂量的血管紧张素转换酶抑制剂对抗因神经-内分泌异常导致的一过性RAAS系统激活,可有一定的益处。更多还原

【Abstract】 Objective To evaluate After the adoption of CO2 pneumoperitoneum during laparoscopic surgery and the CO2 gas pressure on the body absorb the liver and kidney function,blood coagulation, endocrine and hemodynamic effects, etc., objective evaluation of surgical retroperitoneal approach the superiority of this choice for the clinical technology to provide a theoretical basis; surgical patients by testing various indicators during and after the change, and further evaluation of surgical retroperitoneal approach the safety and risks, as the clinical ability to detect various abnormalities, to help patients to smooth out the Perioperative provide an objective theoretical basis.Methods The study of Hebei University Hospital in July 2009 to November 2010 the hospital after passing through the retroperitoneal approach laparoscopic surgery, all patients met the inclusion criteria, Application of a CO2 pneumoperitoneum continuous infusion of high CO2 gas to flow maintain the operating space, gas abdominal pressure maintained at 14mmHg, operation time was 60-240 minutes, mean 150 minutes, were recorded before surgery (T1), the conclusion of surgery (T2), on postoperative day 1 (T3), after surgery 2 days (T4),3 days after operation (T5), respectively, were recorded:1. urine; 2. renal function such as:serum creatinine, urea nitrogen, urine output, carbon dioxide combining power (CO2CP), etc.; 3. Liver power, such as:aspartate aminotransferase, alanine aminotransferase, total bilirubin; 4. clotting function, such as:prothrombin time, thrombin time ratio, activated partial thromboplastin no time, fiber fibrinogen, thrombin time, D-dimer, etc.; 5. hemodynamics, such as:blood pressure, heart rate; 6. endocrinology, such as renin, angiotensin, aldosterone, cortisol, etc.; 6. blood gas analysis, such as:PH value, HCO3-Results different time periods there was no significant difference in heart rate (P> 0.05), systolic and diastolic blood pressure in different time periods were not significantly different (P> 0.05), urine volume changes in different time periods T4, T5 than T1, T2, there was significant difference (P<0.05); serum creatinine and blood urea nitrogen in different time change was no significant difference (P> 0.05), nePHrectomy group and postoperative serum creatinine and blood urea nitrogen change was no significant difference (P> 0.05), carbon dioxide combining power than the T1 T2 change significantly, there was significant difference (P<0.05), gradually returning to normal after the next day, T5 compared with T1, no significant difference (P> 0.05); aspartate aminotransferase, alanine aminotransferase was no significant difference in changes (P> 0.05), total bilirubin T3, T4 was significantly higher than T1, a significant difference (P<0.05); blood coagulation such as:prothrombin time, fibrinogen, D-dimer and so on. D-dimer and prothrombin time before and after surgery there was significant difference (P<0.05), fibrinogen was no significant difference before and after surgery; blood gas analysis, such as:PH value, HCO3-, etc. T2, T3 compared with T1 changes are significantly different (P<0.05), but were within the normal reference range,2 days after gradually returning to normal; endocrine, such as renin, angiotensin, aldosterone changes in T4 was significantly higher than T1 changes differences (P<0.05), cortisol had no significant difference (P> 0.05).Conclusion 1. Lateral position under lumbar retroperitoneal position to raise CO2 pneumoperitoneum on body liver and kidney function in small, nor for the implementation of nePHrectomy in patients with greater impact, the implementation of the same kind of surgery, should be selected by the peritoneal After the way; 2. laparoscopic surgery on the blood coagulation system significantly affected, particularly the longer operative time, affecting more obvious, therefore, should do everything possible to shorten the operative time and improve proficiency in surgical procedures and postoperative treatment to be applied pressure and encourage patients with early ambulation to prevent venous thrombosis and the corresponding pulmonary embolism, cerebral embolism and complications; 3.CO2 gas absorption can lead to lower PH, HCO3-and other changes, and postoperative urine output decreased body metabolism caused by siltation may reinforce each other, further increasing acidosis in patients after surgery, so patients should be at least 3000ml fluid than normal to prevent the urine volume decreased significantly, and proper use of anti-oxidation and reduce free radical damage to the drug; 4.CO2CP a certain temperature and HCO3-in plasma pressure combined with the amount of CO2, the levels reflect the amount of CO2 in vivo, this study shows that postoperative blood CO2CP significantly higher than those before, mainly due to the regulation of CO2 by the lungs, so implementation of laparoscopic Preoperative pulmonary function tests were required to do, for patients with abnormal positive correction should be given until recovery or near normal lung function after surgery, such as severely impaired lung function, improvement can not open surgery is safer should be chosen; 5 retroperitoneal laparoscopic surgery less effect on cortisol, indicating that laparoscopic surgery on the body to stimulate and little interference did not cause significant release of stress hormones, but the surgery caused by renal artery and vein to stimulate the release of renin increase in renin - angiotensin - aldosterone axis activation may be involved in the mechanism of decreased urine output, so perioperative low dose of angiotensin-converting enzyme inhibitors against due to nerve - endocrine disorder caused by a transient activation of RAAS system may have some benefits更多还原