自腹腔鏡問世以來，腹腔鏡手術所特有的戳孔并發(fā)癥也隨之出現(xiàn)，其中戳孔出血就是其特有并發(fā)癥之一。
Since the advent of laparoscopy, the special perforation complications of laparoscopic surgery have also appeared, among which perforation bleeding is one of its unique complications.
戳孔出血的大部分原因是由于氣腹針或 Trocar 穿刺損傷腹壁血管引起的，戳孔出血在外科腹腔鏡手術中發(fā)生率約為 0.85%。
Most of the bleeding was caused by the injury of abdominal vessels by pneumoperitoneum needle or trocar puncture. The incidence of bleeding was about 0.85% in laparoscopic surgery.
戳孔出血大多數(shù)發(fā)生于手術的開始，它的發(fā)生不僅會使術者完成手術的信心受到打擊，而且它還會延長手術時間，嚴重者甚至會導致整臺腹腔鏡手術的失敗。
Most of the perforation bleeding occurs at the beginning of the operation. Its occurrence will not only make the operator's confidence to complete the operation be hit, but also prolong the operation time, even lead to the failure of the whole laparoscopic operation.
那么，對于這個如此痛心疾首的問題，我們該如何處理呢？答案就在本文。
So, how can we deal with such a painful problem? The answer is in this article.
戳孔出血的常見原因
Common causes of bleeding from punctures
首先我們先對腹壁戳孔出血的原因分析一下，一般有以下幾點：
First of all, we will analyze the causes of abdominal perforation bleeding, generally including the following points:
1) 腹壁血管豐富，彼此吻合成網(wǎng)，穿刺操作時有一定的盲目性，容易導致腹壁血管的損傷出血；
1) There are abundant blood vessels in the abdominal wall, anastomosing each other to form a network, and there is certain blindness in the puncture operation, which is easy to cause the injury and bleeding of the blood vessels in the abdominal wall;
2) 標本取出時，特別是體積較大的標本，盲目的擴張或用銳器切開穿刺孔，易損傷腹壁血管 ；
2) When the specimen is taken out, especially the larger specimen, it is easy to damage the abdominal wall blood vessels by blind expansion or cutting through the puncture holes with sharp tools;
3) 穿刺方向未垂直于腹壁，斜向穿刺腹壁的路徑延長，容易損傷腹壁血管；
3) The puncture direction is not perpendicular to the abdominal wall, and the oblique puncture path is prolonged, which is easy to damage the blood vessels of the abdominal wall;
4) 肝硬化靜脈高壓造成腹壁側支循環(huán)開放，凝血功能差等。
4) Cirrhotic venous hypertension results in the opening of collateral circulation and poor coagulation.
戳孔出血的預防措施
Preventive measures of bleeding from puncturing hole
對于腹壁戳孔出血的原因我們大概了解了，那我們該如何預防呢？
We have a general understanding of the causes of abdominal bleeding, so how can we prevent it?
腹腔鏡戳孔出血的預防措施：
The preventive measures of laparoscopic perforation bleeding:
trocar 口出血的主要原因是腹壁血管損傷，多見于側腹部戳孔，也見于臍周 trocar 口。
The main cause of bleeding in trocar mouth is the injury of blood vessels in the abdominal wall, which is often seen in the puncture hole in the side abdomen and also in the trocar mouth around the umbilicus.
對于臍周的戳孔我們可以采取開放法來建立氣腹避免戳孔出血的發(fā)生；側腹部戳孔出血通常是由于術者的麻痹大意損傷了腹壁下動脈引起。
We can establish pneumoperitoneum by opening the puncture hole around the umbilicus to avoid the occurrence of puncture hole bleeding. The puncture hole bleeding in the lateral abdomen is usually caused by the injury of inferior abdominal artery by the operator's numbness.
在這種情況下我們通常可以采用黎建華等（詳見參考文獻 5）介紹的透照法來避開腹壁血管網(wǎng)，從而預防戳孔出血。
In this case, we can usually use the transillumination method introduced by Li Jianhua et al. (see reference 5 for details) to avoid the abdominal vascular network, so as to prevent the perforation bleeding.
但對于腹壁肥厚病人或損傷深層血管出血的病人，此方法就顯得微乎其微了，這時要想避免戳孔出血，必須要求術者熟悉常見腹壁血管的走行，尤其是腹壁動脈血管的走行，該點也是預防穿刺時損傷腹壁血管的關鍵所在。
But for the patients with abdominal wall hypertrophy or deep blood vessel bleeding, this method is very small. In order to avoid puncture bleeding, the operator must be familiar with the common abdominal wall blood vessels, especially the abdominal wall artery vessels. This point is also the key to prevent the injury of abdominal wall vessels during puncture.
那么常見的腹壁血管有哪些，走行又是如何的呢？我們以臍水平面為界限，將腹壁血管分為臍上、下兩個區(qū)域，分別簡介如下：
So what are the common abdominal blood vessels, and how are they going? Taking the horizontal plane of the umbilicus as the boundary, we divide the blood vessels of the abdominal wall into the upper and the lower regions of the umbilicus
A. 臍上
A. Supraumbilical
臍上的動脈又分為淺、深兩層。
The artery on the umbilicus is divided into two layers: shallow and deep.
淺層動脈大都來源于肋間血管發(fā)出的細小分支。
Most of the superficial arteries originate from the small branches of intercostal vessels.
而深層主要有兩條，腹壁上動脈及下位肋間、肋下動脈。腹壁上動脈是發(fā)自于胸廓內(nèi)動脈，走行于腹直肌與腹直肌鞘后層之間，供給腹直肌，并穿過腹直肌及前鞘至腹前壁皮下，與腹壁下動脈分支在臍平面相互吻合。
In the deep layer, there are two main arteries: the superior epigastric artery and the inferior intercostal and subcostal artery. The superior epigastric artery originates from the internal thoracic artery, runs between the rectus abdominis and the posterior layer of the sheath of the rectus abdominis, supplies the rectus abdominis, passes through the rectus abdominis and the anterior sheath to the hypodermis of the anterior epigastric wall, and coincides with the branches of the inferior epigastric artery in the umbilical plane.
B. 臍下
B. Subumbilicus
臍下腹壁動脈同臍上一樣分為深、淺兩層。
The artery of the hypoumbilical abdominal wall is divided into deep and shallow layers as well as that of the supraumbilical.
淺動脈層主要有兩條，分別是腹壁淺動脈及旋髂淺動脈。腹壁淺動脈越腹股溝韌帶中內(nèi) 1/3 向臍部走行；旋髂淺動脈起始部常較腹壁淺動脈高出 1 cm，在淺筋膜淺深兩層之間向髂前上棘走行。
There are two main arteries in the superficial arterial layer: the superficial abdominal artery and the superficial circumflex iliac artery. The origin of the superficial circumflex iliac artery is usually 1 cm higher than that of the superficial abdominal artery, and runs between the superficial and deep layers of the superficial fascia to the anterior superior iliac spine.
深層也有兩條主要的血管，分別是腹壁下動脈及旋髂深動脈。腹壁下動脈是近腹股溝韌帶中點稍內(nèi)側處發(fā)自髂外動脈，穿腹橫筋膜上行于腹直肌與腹直肌鞘后層之間，至臍平面附近與腹壁上動脈吻合；
There are two main vessels in the deep layer, the inferior abdominal artery and the deep circumflex iliac artery. The inferior epigastric artery originates from the external iliac artery at the medial point of the inguinal ligament, and runs up between the rectus abdominis and the posterior sheath of the rectus abdominis through the transverse abdominal fascia, and anastomoses with the superior epigastric artery near the umbilical plane;
旋髂深動脈與腹壁下動脈起自同一水平，在腹膜外組織內(nèi)沿著腹股溝外側半的深面斜向外上方，行向髂前上棘內(nèi)側，至髂肌和髂骨等。
The deep circumflex iliac artery and inferior epigastric artery originate from the same level. In the extraperitoneal tissue, they incline outwards and upward along the deep side of the lateral half of the groin, to the medial side of the anterior superior iliac spine, to the ilium muscle and ilium bone.
血管損傷的處理策略
Management strategy of vascular injury
在現(xiàn)實中，我們雖然對腹壁血管的走行已經(jīng)非常熟悉了，但是還有一部分人腹壁血管走行存在變異，導致我們在穿刺中不幸地損傷了腹壁血管，這時我們該怎么辦？放棄腹腔鏡手術選擇傳統(tǒng)的開腹嗎？
In reality, although we are very familiar with the course of the abdominal wall vessels, there are still some people with the variation of the course of the abdominal wall vessels, which leads to the unfortunate injury of the abdominal wall vessels during the puncture. What should we do? Give up laparoscopic surgery and choose traditional open surgery?
答案是否定的。因為腹壁的戳孔出血一般都是損傷腹壁的小血管，它不同于 trocar 損傷腹腔內(nèi)大血管（如腸系膜上動脈、腹主動脈、下腔靜脈、髂血管）那樣來勢兇險，處理不及時患者就危在旦夕；
The answer is No. Because the puncture hemorrhage of the abdominal wall is usually the small blood vessels which damage the abdominal wall, it is different from the trocar which damages the large blood vessels in the abdominal cavity (such as the superior mesenteric artery, the abdominal aorta, the inferior vena cava and the iliac blood vessels), so it is dangerous to deal with the patients in time;
腹壁小血管的損傷沒有那么兇險，允許我們從容不迫的處理，如果處理得當能使我們的腹腔鏡手術如期地進行下去。
The injury of the small blood vessels in the abdominal wall is not so dangerous, which allows us to deal with it calmly. If we deal with it properly, our laparoscopic operation can go on as scheduled.
那么對于 trocar 引起的腹壁小血管損傷我們該如何處理呢？有如下幾種方法：
So what should we do about the injury of small blood vessels in abdominal wall caused by trocar? There are several methods:
1) 從外面直接壓迫，這時需要一些耐心，壓迫至少 5 分鐘！期間切忌每隔 5 秒鐘就掀開來瞥一眼；
1) Direct pressure from outside, at this time need some patience, pressure at least 5 minutes! Do not open it every 5 seconds to catch a glimpse;
2) 壓迫止不住血的戳孔可以拔出 trocar 找到出血點，通過結扎、縫合 、電凝等技術將其止?。?/div>
2) Trocar can be pulled out to find the bleeding point by pressing the puncture hole which can not stop the blood, and it can be stopped by ligation, suture, electrocoagulation and other technologies;
3) 從里面壓迫，方法是把 Foley 導尿管經(jīng) trocar 孔插入腹腔，充氣向后拽緊尿管；
3) The method of pressing is to insert Foley catheter into abdominal cavity through trocar hole, and pull the catheter tightly after inflation;
4) 在出血的動脈處通過腹壁縫合止血，這需要在腹腔鏡引導下借助縫合引導器進行。
4) Hemostasis is achieved by abdominal wall suture at the bleeding artery, which needs to be performed under the guidance of laparoscope with the aid of suture guide device.
結 束 語
Conclusion
腹腔鏡技術在我國基層醫(yī)院得到了很好的普及，一臺腹腔鏡手術成功與否不僅取決于腹腔內(nèi)操作的情況，而且還包括進入腹腔之前準備，如腹腔穿刺。
Laparoscopic technology has been widely used in primary hospitals in China. The success of a laparoscopic operation depends not only on the operation in the abdominal cavity, but also on the preparation before entering the abdominal cavity, such as abdominal puncture.
成功的腹腔穿刺有利于手術的順利進行，不成功的腹腔穿刺不僅能影響手術完成的進度，而且嚴重者能夠?qū)е抡_腹腔鏡手術的失敗。所以對于腹腔鏡技術日益成熟的外科醫(yī)生們，應該更加關注戳孔出血問題，提高警惕、避免麻痹大意，從根源上預防戳孔出血發(fā)生。
Successful abdominal puncture is conducive to the smooth operation. Unsuccessful abdominal puncture can not only affect the progress of the operation, but also lead to the failure of the whole laparoscopic operation. Therefore, surgeons with more and more mature laparoscopic technology should pay more attention to the problem of perforation bleeding, improve their vigilance, avoid numbness and carelessness, and prevent the occurrence of perforation bleeding from the root.
This article is organized by the endoscope equipment maintenance. If you want to know more, please consult the official website http://m.daybang.cn.
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