完全电视胸腔镜外科手术治疗胸部创伤并多发肋骨骨折临床分析
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摘要
目的探讨完全电视胸腔镜外科手术(VATS)对胸部创伤并多发肋骨骨折病例在完成探查、修补,以及同期微创治疗肋骨骨折的手术方式及疗效。方法对2016年1月至2018年11月收治的22例多根多处肋骨骨折合并创伤性血气胸、进行性血胸、连枷胸、膈肌破裂、胸腔内异物等需胸腔镜探查的胸部创伤患者,在电视胸腔镜下完成胸内手术的同期、同切口行微创治疗肋骨骨折。结果 22例患者均顺利"借助"主和/或副操作孔,不切断胸部肌肉,"隧道式"游离、固定多发肋骨骨折,无中转开胸病例,其中3例增加脊柱旁纵切口。术后并发症包括切口延期愈合3例,经全身抗炎治疗、局部换药痊愈;肺漏气1例,加强胸腔引流的管理,第7天拔除胸腔闭式引流管。所有患者肋骨固定可靠,愈合良好。术后肋间神经痛1例,胸部麻木感3例,局部胸膜增厚6例。结论具有胸腔镜探查指征、并多根多处肋骨骨折的胸部创伤,利用胸腔镜切口,在不增加额外损伤的基础上,同期固定骨折的肋骨,安全可行,能明显减轻疼痛,具有并发症少、恢复快的优点。
Objective To evaluate the surgical approaches and effectiveness of exploration, repair and homeochronous micro-invasive treatments of rib fractures for multiple fractured ribs with chest traumas through complete video-assisted thoracoscopic surgery(VATS). Methods The clinical data of 22 cases of multiple fractured ribs with chest traumas such as traumatic hemopneumothorax, open chest trauma, progressive hemothorax, flail chest, rupture of the diaphragm, and intrathoracic foreign body in our hospital from January 2016 to November 2018 were retrospectively analyzed. Results Satisfactory effect of stabilization of chest wall were obtained in all the 22 patients with rib fractures using VATS exploration. We carried out exploration, hemostasis, lung-repair and diaphragm repair first, then dissected and exposed the broken end of ribs through operating holes without cutting off chest muscles, and selectively focused on stabilizing multi-fractures of ribs finally. No conversion to thoracotomy in this cohort. All the cases were successfully completed with the operation of rib fracture internal fixation under VATS, based on primary and/or auxiliary operating holes, except 3 cases with added longitudinal incision nearby spinal column. Delayed incision healing occurred in 3 cases and cured with systemic anti-biotics and local dressing changes. Pulmonary air leakage occurred in 1 case, and treated by closed drainage of thoracic cavity and chest tube was removed in 7 days. Follow up results showed reliable rib fixation and satisfactorily bony union. Intercostal neuralgia occurred in 1 case. Numbness of the chest occurred in 3 cases. Local pleural thickening occurred in 6 cases. Conclusions For chest trauma with fractures of multiple ribs, which satisfies the standards of thoracoscopic exploration, homochromous fixation of fractured ribs using exploratory incision of thoracoscope is safe and feasible. This procedure has advantage of rapid recovery and fewer complications, without adding extra injury.
Objective To evaluate the surgical approaches and effectiveness of exploration, repair and homeochronous micro-invasive treatments of rib fractures for multiple fractured ribs with chest traumas through complete video-assisted thoracoscopic surgery(VATS). Methods The clinical data of 22 cases of multiple fractured ribs with chest traumas such as traumatic hemopneumothorax, open chest trauma, progressive hemothorax, flail chest, rupture of the diaphragm, and intrathoracic foreign body in our hospital from January 2016 to November 2018 were retrospectively analyzed. Results Satisfactory effect of stabilization of chest wall were obtained in all the 22 patients with rib fractures using VATS exploration. We carried out exploration, hemostasis, lung-repair and diaphragm repair first, then dissected and exposed the broken end of ribs through operating holes without cutting off chest muscles, and selectively focused on stabilizing multi-fractures of ribs finally. No conversion to thoracotomy in this cohort. All the cases were successfully completed with the operation of rib fracture internal fixation under VATS, based on primary and/or auxiliary operating holes, except 3 cases with added longitudinal incision nearby spinal column. Delayed incision healing occurred in 3 cases and cured with systemic anti-biotics and local dressing changes. Pulmonary air leakage occurred in 1 case, and treated by closed drainage of thoracic cavity and chest tube was removed in 7 days. Follow up results showed reliable rib fixation and satisfactorily bony union. Intercostal neuralgia occurred in 1 case. Numbness of the chest occurred in 3 cases. Local pleural thickening occurred in 6 cases. Conclusions For chest trauma with fractures of multiple ribs, which satisfies the standards of thoracoscopic exploration, homochromous fixation of fractured ribs using exploratory incision of thoracoscope is safe and feasible. This procedure has advantage of rapid recovery and fewer complications, without adding extra injury.
引文
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2 王通,宋金涛,闫天生.电视胸腔镜辅助肋骨接骨板治疗多发肋骨骨折合并血气胸[J].中国微创外科杂志, 2016, 16(13):245-248.
3 李树坡,李鹏,余捍东. 胸腔镜在多发肋骨骨折固定中的应用[J].中国创伤外科杂志,2018,20(7):499-502.
4 胡为才,邵换璋,张全. 胸腔镜辅助下形状记忆肋骨环抱接骨板内固定治疗多发性肋骨骨折的临床研究[J]. 中国创伤外科杂志,2018,20(2):88-91.
5 Nanavati AJ,Prabhakar S.Fast-track surgery:toward comprehensive peri-operative care[J]. Anesth Essays Res, 2014,8(2)127-133.
6 朱文,刘涛,劳海军.电视胸腔镜经乳腺外下缘小切口经隧道式胸壁结核病灶清除术1例[J]. 结核病与肺部健康杂, 2017,6(1):87-88.
7 林冰,李树维,朱文.电视胸腔镜经乳晕切口隧道式胸壁结核病灶清除术治疗男性胸壁结核一例[J].中国医师进修杂志,2018,6(1):87-88.
8 王斌强. 镍钛环抱式接骨器内固定修复多发性肋骨骨折:与克氏针应用安全性比较[J].中国组织工程研究,2015,19(21):3419-3423.
9 Tarng YW, Liu YY, Huang FD, et al.The surgical stabilization of multiple rib fractures using titanium elastic nail in blunt chest trauma with acute respiratory failure[J]. Surg Endosc, 2016,30(1):388-395.
10 牛世海.胸腔镜辅助小切口镍钛记忆合金肋骨接骨板固定治疗多发肋骨骨折的疗效研究[J].河北医药,2016,38(3):368-370.
11 赖小刚,王宪东.镍钛记忆合金环抱器治疗多发性肋骨骨折的临床分析[J].临床军医杂志,2015,43(1):85-86.
12 Lee SK, Kang do K. Nuss procedure for surgical stabilization of flail chest with horizontal sternal body fracture and multiple bilateral rib fractures[J]. J Thorac Dis,2016,8(6):e390-392.
2 王通,宋金涛,闫天生.电视胸腔镜辅助肋骨接骨板治疗多发肋骨骨折合并血气胸[J].中国微创外科杂志, 2016, 16(13):245-248.
3 李树坡,李鹏,余捍东. 胸腔镜在多发肋骨骨折固定中的应用[J].中国创伤外科杂志,2018,20(7):499-502.
4 胡为才,邵换璋,张全. 胸腔镜辅助下形状记忆肋骨环抱接骨板内固定治疗多发性肋骨骨折的临床研究[J]. 中国创伤外科杂志,2018,20(2):88-91.
5 Nanavati AJ,Prabhakar S.Fast-track surgery:toward comprehensive peri-operative care[J]. Anesth Essays Res, 2014,8(2)127-133.
6 朱文,刘涛,劳海军.电视胸腔镜经乳腺外下缘小切口经隧道式胸壁结核病灶清除术1例[J]. 结核病与肺部健康杂, 2017,6(1):87-88.
7 林冰,李树维,朱文.电视胸腔镜经乳晕切口隧道式胸壁结核病灶清除术治疗男性胸壁结核一例[J].中国医师进修杂志,2018,6(1):87-88.
8 王斌强. 镍钛环抱式接骨器内固定修复多发性肋骨骨折:与克氏针应用安全性比较[J].中国组织工程研究,2015,19(21):3419-3423.
9 Tarng YW, Liu YY, Huang FD, et al.The surgical stabilization of multiple rib fractures using titanium elastic nail in blunt chest trauma with acute respiratory failure[J]. Surg Endosc, 2016,30(1):388-395.
10 牛世海.胸腔镜辅助小切口镍钛记忆合金肋骨接骨板固定治疗多发肋骨骨折的疗效研究[J].河北医药,2016,38(3):368-370.
11 赖小刚,王宪东.镍钛记忆合金环抱器治疗多发性肋骨骨折的临床分析[J].临床军医杂志,2015,43(1):85-86.
12 Lee SK, Kang do K. Nuss procedure for surgical stabilization of flail chest with horizontal sternal body fracture and multiple bilateral rib fractures[J]. J Thorac Dis,2016,8(6):e390-392.