專(zhuān)家講堂第九腹腔鏡手術(shù)麻醉管理

Whoelsehasnotdonelaparoscopicsurgery還有誰(shuí)沒(méi)做過(guò)腹腔鏡手

Hand-手助腹腔

機(jī)器人ALittle腹腔鏡發(fā)展

In1985(103yearslater)Dr.ErichMüheofGermanyperformedthefirstLaparoscopicCholecystectomy 1882年，首例膽囊切除 1985年，首例腔鏡膽囊切除ThesurgicalProcedurescanbedone可通過(guò)腹腔鏡技術(shù)實(shí)施的外科手Complicatedgastrointestinal(eg.distalgastrectomyforgastriccancerpatientswithcomorbiddiseases,laparoscopichepaticresectionforcolorectalcancerlivermetastases,andlaparoscopicresectionordebulkingofpresacralandretrorectalspacetumors)復(fù)雜胃腸道手術(shù)Almostallthegenitourinaryprocedures泌尿生殖系統(tǒng)AlmostalltheGynecologicalprocedures婦科手Russoaetal.,2009,EurJ一般醫(yī)專(zhuān)科化LaparoscopicProsand腹腔鏡手術(shù)的優(yōu)Pros（腹腔鏡手術(shù)的優(yōu)點(diǎn)Minimizingthetraumaticandmetabolicstressofintervention降低手術(shù)及代謝應(yīng)激Tissuetraumaissignificantlylessthanthatwithconventionalopenprocedures,thusresultsintheadditionalbenefitofreducedpost-operativepain組織損傷明顯降低，Smallerincisionalsites,lowerrisksofwound相對(duì)小的切口，切口相關(guān)并發(fā)癥Shorterhospitalstay,morerapidreturntonormal縮短住院時(shí)間，加快康復(fù)至正?；頒arther,2011,WorldJSurg;Nicholsen,2011,Leonard&Cunningham,2002,BestPractResClinCons（腹腔鏡手術(shù)的缺點(diǎn)laparoscopicsurgerymayresultinseriouscomplicationsduetotheimportantphysiologicchangeswhichoccurduringtheIncomplicatedsurgicalcasesofextendedduration.復(fù)雜手術(shù)時(shí)間延長(zhǎng)（注：機(jī)器人的出現(xiàn)可能縮短時(shí)間）Theprolongedsteeppositionandcarbondioxideinsufflationresultsinap whichoftenhasadversehaemodynamicandrespiratoryconsequences.(Russoaetal.,2009,EurJAnaesth)長(zhǎng)時(shí)間變化及CO2氣腹導(dǎo)致血流動(dòng)力Negativeaspectsoflaparoscopicsurgeryintermsofthesurgicalprocedureitselfincludepoorvisualizationandtraumaticinjuriestovisceraandbloodvesselsassociatedwithblindtrocarinsertion.部分手術(shù)外科視野不佳，戳卡盲探進(jìn)入時(shí)的損傷（注：機(jī)器人的出現(xiàn)也可能部分改善）US48RCT,873coloncancerundergoopenorlapresection,4.4yearfollowup48個(gè)中RCT研究，873例結(jié)腸癌患者接受開(kāi)腹或腔鏡手術(shù)，隨AllStage5YearSurvivalConclusion:theratesofrecurrentcancerweresimilarafterlaparoscopicallyassistedcolectomyandopencolectomy,suggestingthatthelaparoscopicapproachisanacceptablealternativetoopensurgeryforcoloncancer.結(jié)論：腹腔鏡輔助結(jié)腸切除術(shù)與開(kāi)放手術(shù)的復(fù)發(fā)率相似，表明腹腔鏡可替腹用于結(jié)腸癌手術(shù) 腹 的三種問(wèn) （氣腹 （氣腹Abdominalinsufflationwithgasto~15mmHg（氣腹壓力達(dá)-NormalIntra-abdominalpressure(IAP)<5（正常腹壓Twoeffects（兩方面的影響Mechanic（機(jī)械Chemical（化學(xué) :Intraabdominal氣腹:用于充在腹腔里IdealGas（理想氣體Nontoxic無(wú)OdorlessColorlessNonflammable不可Highlysolubleinblood血液中高溶Metabolicallyandchemicallyinert代謝和化學(xué)InexpensiveThereisNOsuchidealgasinthe有木有？此曲只應(yīng)天上有InsufflationGas:氣體溶WolfS,1996,SurgicalRobertsetal.,1997,SurgicalCO2PP:PathophysiologicalCO2氣腹的病理生 :Mechanic氣腹的機(jī)械性Physiologicaleffectof 氣腹的PerrinM,FlecherA,2004,CriticalCare&SummaryofHaemodyanamicChangesdueMechanicalpressureofCO2氣腹導(dǎo)致的血流動(dòng)Minimalalternationinheartbeat MeanArterialpressureCerebralbloodflowRenalbloodflowPortalbloodSplanchnicbloodPulmonary氣腹的病理生理學(xué)Highintra-abdominalpressure(IAP)（高腹Intraperitoneal>extraperitoneal腹內(nèi)> Absorptionofinsufflationgas（氣體吸收）ExtraperitonealintraperitoneallaparoscopyIntraperitonealvsExtraperitoneal腹腔內(nèi)VS腹腔外Mulletetal.,1993, TheTrendelenburg頭低FirstdescribedbyGermansurgeonFriedrichTrendelenburg(1844-1924)in1873.首次于1873

abdominalorgansupfromtheoperativefield,thusimproving常用于盆腔手術(shù)，依靠重力作用使腹腔臟器上移以充分顯露PhysiologicalEffectof導(dǎo)致的生理 part:GU,GYN最常見(jiàn)于盆腔手術(shù):泌尿,婦科手術(shù)

Mostlikelyupperabdsurgerysuchaslap最常見(jiàn)上腹部如腹腔膽囊PerrinM,FlecherA,2004,CriticalCare&ChangesinBloodGas,AcidBase,andOxygen(氣腹 )對(duì)血?dú)?酸堿和氧耗的影 TEEandIAPand*P=0.01vsP?p=0.01vsP?p=0.01vsP

RistMetal.,2001,JClin“Dark”hastwo ”有著兩層意思-Anesthesiaindarkroom對(duì)麻醉來(lái)說(shuō)手術(shù)-Surgeonlost3-Dvision對(duì)外科醫(yī)生來(lái)說(shuō),失去三維視Anesthesiain 中”的麻Drugandothererror錯(cuò)誤用藥43y/ofemaleforLC.15min startedpatientbecamehypertensive.TreatedwithLabetalolandpatient’sBP230/130andHR180s.gotveryangryandaskedwhatisgoingDrugError:Dobutaminewas機(jī)器人AdvancesinAnesthesia30(2012)當(dāng)頭低位時(shí)氣管導(dǎo)管滑AdvancesinAnesthesia30(2012)

氧氧化Hemodynamicchangesthroughoutthe（在氣腹 合并作用下）整個(gè)過(guò)程血液動(dòng)力學(xué)變 g腹腔鏡手術(shù)是否需要肌德國(guó)慕尼黑大學(xué)，57位（ASA1至3）在全組給0.6mg/Kg溴胺。對(duì)照組用生理鹽水。麻醉醫(yī)師由 施藥和肌松監(jiān)測(cè) SurgEndosc20140n0.3mg/Kg似等級(jí)(VAS)給予 ysisofNMRtoLaparoscopic肌松劑與腹腔鏡NMBisassociatedwithoptimisedsurgicalconditionsduringlaparoscopicsurgeries(gradeof A).Itcanlowerp (8mmHg建議應(yīng)用肌松Thereisgoodevidence(gradeof mendationA)to improvesurgicalconditions.Thereisinsufficientevidence mendanideallevelofNMBcreatingoptimalsurgicalconditionduringlaparotomy.循證建議深肌松（直收縮0至2）在腔鏡膽囊切除、腎切除和切除術(shù)中可改善外科條件。而在開(kāi)腹手術(shù)中沒(méi)有足夠顯示什么樣的肌松水平可優(yōu)ActaAnaesthesiologicaScandinavica2015;59:妊娠期腹腔鏡Theadvantagesoflaparoscopicsurgeryaresimilarforpregnantandnonpregnantwomen;nevertheless,thisprocedurehadbeenavoidedduringpregnancybecauseofconcernsthatitmaybeharmfultothe Theriseinintraabdominalpressureduringp decreaseutero-placentalbloodflowandresultinfetalhypoxia由氣腹而導(dǎo)致的腹內(nèi)壓增高可降 -胎盤(pán)血流而造 缺Fetalacidosiscoulddevelopfromabsorptionofcarbondioxide perforatedbyatrocarorVeress戳卡置入時(shí)可能傷

SAGES胃腸腹腔鏡外科醫(yī)師學(xué)會(huì)指Guideline7:Diagnosticlaparoscopyissafeandeffectivewhenusedselectivelyinworkupandtreatmentofacuteabdominalprocessesinpregnancy(Moderate;診斷性腹腔鏡在急腹癥的妊娠中的應(yīng)用是安全Guideline8:Laparoscopictreatmentofacuteabdominaldiseasehasthesameinpregnantandnon-pregnantpatients(Moderate;Strong).指征與未妊 相Guideline9:Laparoscopycanbesafelyperformedduringanytrimesterof(Moderate;Strong).腹腔鏡手術(shù)可在任何妊娠期間安全Guideline10:Gravidpatientsshouldbeplacedintheleftlateraldecubituspositiontominimizecompressionofthevenacava(Moderate;Strong). Guideline11:Initialabdominalaccesscanbesafelyperformedwithanopen(Hasson)techniqueVeressneedleoropticaltrocarifthelocationisadjustedaccordingtofundalheightandpreviousincisionsModerateWeak).放置介入器時(shí),應(yīng)用開(kāi)放技術(shù)(即漢森法)InsufflationPressureGuideline12CO2insufflationof10-15mmHgcanbesafelyusedforlaparoscopyinthepregnantpatient(Moderate;Strong).氣腹應(yīng)限于10至15以內(nèi)Intra-operativeCO2monitoringGuideline13:IntraoperativeCO2monitoringbycapnographyshouldbeusedduringlaparoscopyinthepregnantpatientModerate;Strong).術(shù)中應(yīng)作二氧化碳監(jiān)測(cè)RelativelyUnique腔鏡手術(shù)特有并Subcutaneousemphysema皮下氣 othorax omediastinum opericardium心包積GasembolismEndobronchialintubation支氣管內(nèi)PeripheralnervedamageVeressneedle/trocar氣腹針/62y/omalewasscheduledfordiagnosticlaparoscopy.Patientwasdiagnosedasgastriccancer8monthsagoandrefusedtohavesurgeryattime.Patientcamebackandrequestedsurgeryfordifficultswallowing.62歲，胃癌，因吞 擬行腹腔鏡探查PMHx/PSHx:CVA,R.anklesurgeryandPortplacement.(-)problemswithanesthesia既往史及手術(shù)史：CVA、右踝手Allergies:Meds:Prochlorperazine,andSocHx:(+)55p/ysmoker,(-)EtOH&Funct.Capacity:4-6PhysicalExam:125/75,HR83,DL,7.5ETT@

20GL.armPIVpre-16GR.handHowHowwouldyouWhatWhatareotheroptionsfortheR.femoralVASweep10L/min4FWhatother4FWhatotheractionstoconsiderafterresuscitation?LiverinjuryPOD

Post-opCourse術(shù)后情gag&pupillaryreflexes加重，瞳孔反射HeadCTshowsR.parietalCT示右頂葉EEGshowsmod.POD

ToORforabdomenclosureECMOdecannulation關(guān)腹，撤Transitionedtoepinephrine&epoprostenol使用腎上腺素與依前列醇POD#4-7:Distalischemia遠(yuǎn)端缺Fevers發(fā)Neurostatusimprovement神經(jīng)系統(tǒng)評(píng)分改TTEshowssevereglobalhypokinesis,EF<30%全心運(yùn)動(dòng)減Ontheday5pathologyreport:abdominalwallcancer術(shù)后第5天病理結(jié)果：腹壁轉(zhuǎn)移PODCarewithdrawn,pt.expires和家屬討 的預(yù)后和轉(zhuǎn)歸后家屬同意生命支持CauseofunreasonablyincreasedCO2異常升高的NormallyCO2elevationiscommon(slightly)輕度升高為Sometimesalsocausedbyincreasedmetabolisminsufficientplaneofanesthesia,orfever)ordepressionofventilationbyanesthetics(spontaneousbreathing)代謝增加或通氣不足IfitisunreasonablethefollowingshouldbeCO2embolism氣栓Bronchialintubation支氣管插CopnothoraxSurgicalEmphysemaandCO2Fourcasesofabdominallaparoscopicsurgerywithinaone-yearperiodFourcasesofabdominallaparoscopicsurgerywithinaone-yearperiodwheretheETCO2andCO2loadincreasedtoanunexpectedlyhighlevelduringlaparoscopy.Extensivesurgicalemphysemawaslaterfoundinallfourcases.Wolfetal.,1995,JAmCollManagementofSubc皮下氣腫的處-Sometimesitisimpossibletosufficientlyincrease-MayfacilitatemechanicalIfPETCO2remainstoohigh頑固-Limitdurationofsurgery縮短手術(shù)-Abolishlaparoscopicprocedure根據(jù)血CO2壓及綜合評(píng)估，放棄腹腔鏡手DeterminedbyPCO2andcardiopulmonaryCO2GasEmbolism（二氧化碳?xì)馑╒enousCO2embolism:mechanisms靜脈氣栓機(jī)-EarlyafterVeressneedleinsertionduringinductionofPP)氣腹針置入時(shí)（腹初期-Directintravenousinsufflation靜脈注Gaslockinvcavaandrightatrium氣體進(jìn)入下腔和右房fallinoutput,evencirculatoryarrest心輸出量下降甚至心臟-PassageofCO2intoabdominalwallandperitonealvessels氣體進(jìn)入腹腔及壁血-Openvesselsonliversurfaceduringgallbladderdissection膽囊切除術(shù)肝臟面血管進(jìn)ParadoxalembolismthroughpatentforamenovaleorASD氣栓逆行通過(guò)卵圓孔-Acuterightventricularhypertension右室壓力急劇升-CerebralCO2embolism顱內(nèi)氣LethalvolumeofCO2embolismisfivetimesgreaterthanair二氧化碳?xì)馑ǖ闹滤廊莘e為空氣的5Signsandsymptoms癥狀與體征DecreaseinPETCO2呼末CO2降低-SometimesprecededbyanincreaseinPETCO2due-pulmonaryexcretionofabsorbed“Mill-wheelmurmurCO2Embolism:氣栓 ystopinsufflationandreleaseofPP立即Durant’spositiontoclearrightventricularAspirationofgas通過(guò)中心靜脈導(dǎo)管抽Cardiopulmonaryresuscitation心肺 二氧化碳Etiology:CO2traversingdiaphragmtoenterthepleuralspace,resultingincapnothorax(2%)導(dǎo)致原因:二氧化碳通過(guò)膈肌進(jìn)入胸腔而產(chǎn)生，發(fā)生率約Clinical:Awake:Dyspnea,ChestPain,Respiratory臨床表現(xiàn)：清 ，呼 ，胸痛，呼衰全 ，血液動(dòng)力學(xué)不穩(wěn)定，呼未二氧化碳升高，氣道壓增高minutes-onehour)withouttreatment->chesttubeistypicallynot治療：支持，觀察。多數(shù)恢復(fù)很快(吸收)(數(shù)分鐘到一小時(shí)間)。胸管基本上需要Prevention:MaintenanceofModerate-to-LowIntra-AbdominalPressure(<12mmHg)Durin