经脐无气腹单孔腔镜联合罗哌卡因局部浸润麻醉在妊娠合并卵巢肿瘤中的应用.pdf

药物治疗学摘要目的：研究妊娠合并卵巢肿瘤患者应用经脐无气腹单孔腔镜联合罗哌卡因局部浸润麻醉的临床疗效及安全性。方法：28例妊娠患者合并卵巢肿瘤行经脐无气腹单孔腔镜手术，按随机数字表分2组，观察组16例采用腰麻联合缝皮前罗哌卡因浸润麻醉，对照组12例采用腰麻，比较两组孕妇术后首次下床时间、通气时间、术后住院天数，术后 6 h 无创血压、心率（HR）、呼吸频率（RR）、血氧饱和度（SpO2），Ramsay镇静评分、术后6、24、48 h静息和运动状态下的疼痛评分，SAS焦虑评分、术后并发症、患者满意度、恢复质量表QoR15。结果：两组比较，术后住院天数、Ramsay评分、RR、SpO2及并发症发生率差异无统计学意义（P0.05）；观察组下床时间、通气时间缩短，无创血压、HR、疼痛评分、焦虑评分低于对照组，患者满意度、QoR15评分优于对照组，差异有统计学意义（P0.05）。1.2术前准备完善相关术前检查，两组孕妇均无手术禁忌。术前术后12 h予以黄体酮20 mg肌肉注射，降低子宫敏感度。术前不灌肠，常规禁食 8 h、禁饮 4 h。入室后监测生命体征：心率（HR）、无创血压（收缩压、舒张压）、呼吸频率（RR）、血氧饱和度（SpO2）。1.3麻醉用药嘱患者左侧膝胸卧位，保证脊柱的完全暴露，穿刺部位选择L3-4间隙，穿刺成功后注射0.75%布比卡因（批准文号：20221202，晋城海斯制药有限公司），注射速度以1015 mL/min为宜，转平卧位予以面罩氧气4 L/min，腰麻诱导后10 min内，针刺法双侧T8感觉平面疼痛消失，且不用静脉辅助镇痛完成手术，即定义为腰麻有效。观察组在腰麻的基础上，皮肤缝合前加用0.75%罗哌卡因（批准文号：22111651，石家庄四药有限公司）10 mL局部浸润麻醉，于单孔脐部切口处、皮下、肌肉注射回抽未见回血。1.4手术方式28例妊娠合并卵巢肿瘤患者住院行经脐悬吊式无气腹单孔腹腔镜下卵巢囊肿剥除+卵巢成形术，手术顺利，无中转开腹手术，术中出血不多，麻醉满意。主要操作步骤：安装腹壁悬吊系统，取脐部垂直切口23 cm，逐层进腹，置入单孔切口保护套，患者头低足高位，悬吊形成操作空间。置镜探查（Fig.1），镜下见增大子宫，可选择腹腔镜下完成卵巢囊肿剥除+卵巢成形术。若卵巢囊肿较大，亦可牵拉至脐部切口处直视下操作，降低单孔手术难度同时又能避免腹腔操作器械对妊娠子宫的干扰。ABCD1 cmFig.1Intraoperative findingsA:laparoscopic view of uterus and ovaries of pregnancy.B:laparoscopic view of uterus,ovaries and fallopian tubes of pregnancy.C:ovariantumor pulled into the umbilical cord incision.D:local infiltration anesthesia with ropivacaine was performed before suturing.1.5观察指标记录并比较：（1）一般资料：年龄、孕周、体质量、病变部位、ASA分级、手术时长。（2）患者恢复情况：术后首次下床时间、通气时间、术后住院天数。（3）生命体征监测：术前及术后6 h无创血压（收缩压、舒张压）、HR、RR、SpO2。（4）镇痛、镇静评分：苏醒时Ramsay镇静评分，术后 6、24、48 h 静息和运动状态下的 VAS 疼痛评分。（5）焦虑评分：患者术前、术后心理状况评估采用焦虑自评量表SAS。（6）术后并发症发生率：包括恶心呕吐、头晕、流产、呻吟体动等。（7）患者满意度：采用自主设计满意度调查表，满意90100分、一般7089分、不满意69分。（8）恢复质562中国临床药理学与治疗学 2024 May;29(5)量表QoR15及脐部切口愈合情况。1.6统计学处理应用SPSS 26.0进行统计学处理，计量资料以均数标准差（x s）表示，符合正态分布的计量资料采用t检验，非正态分布的计量资料采用秩和检验。计数资料采用Fisher精确概率检验，以P0.05为差异有统计学意义。2结果2.1妊娠患者术后恢复情况与对照组相比，观察组妊娠患者术后首次下床时间、通气时间缩短，差异有统计学意义（P0.05），见 Tab.1。28 例妊娠患者术后无腹痛腹胀无宫缩、无阴道流血流液，其中对照组1例术后出现恶心、呕吐明显，观察组1例术后出现轻度恶心。两组脐部切口愈合良好，卵巢肿瘤病理为良性，随访宫内胎儿正常生长且均顺利生产，其中顺产25例，剖宫产3例，3例产妇剖宫产术中均未见明显粘连，该术式对于分娩方式无明显影响。Tab.1Postoperative recovery of pregnant women in the two groupsGroupObservation groupControl grouptPn1612First time out of bed aftersurgery(d)1.060.251.580.672.5670.023Duration of ventilation(d)1.130.341.580.512.6740.015Postoperativehospital stay(d)3.501.104.831.033.2690.003Complication1(6.25%)1(8.33%)-0.560-indicatedFishertest.2.2生命体征监测术前两组患者收缩压、舒张压、HR两组差异无统计学意义（P0.05）。与对照组相比，观察组术后6 h收缩压、舒张压、HR、RR均低于对照组，差异有统计学意义（P0.05，Tab.2）。两组患者术前、术后收缩压、舒张压、HR结果详见Tab.3-5。Tab.2Vital signs 6 hours after operation of the two groupsGroupObservation groupControl grouptPn1612Systolic pressure(mm Hg)105.1312.45119.4212.123.0400.005Diastolic pressure(mm Hg)65.315.2073.508.133.0520.007HR(Times/min)73.6310.2883.089.252.5120.019RR(Times/min)17.000.8217.921.002.6760.013SpO2(%)99.310.9599.171.030.3890.701Tab.3Preoperative and postoperative systolic pressureGroupObservation groupControl grouptPn1612Systolic pressure(mm Hg)Preoperation107.567.68108.338.630.2490.805Postoperation105.1312.45119.4212.123.0400.005t0.6672.580P0.5100.0172.3镇痛、镇静评分及QoR15与对照组相比，观察组妊娠患者术后6、24、48 h静息和运动状态下的VAS疼痛评分均低于对照组，差异有统计学意义（P0.05）；两组患者恢复质量表QoR15评分，差异具有统计学意义（P0.01），结果详见Tab.7。563Chin J Clin Pharmacol Ther 2024 May;29(5)Tab.4 Preoperative and postoperative diastolic pressureGroupObservation groupControl grouptPn1612Diastolic pressure(mm Hg)preoperation68.314.6166.174.751.2030.24postoperation65.315.2073.508.133.0520.007t1.7262.699P0.0950.015Tab.5Heart rate before and after operationGroupObservation groupControl grouptPn1612HR(time/min)preoperation78.388.0575.925.900.8920.381postoperation73.6310.2883.089.252.5120.019t1.4552.263P0.1560.036Tab.6Resting and exercise VAS scores of the two groups at different time points after surgery(x s,score)GroupObservation groupControl grouptPn1612Resting VAS score6 hafter surgery2.810.754.000.744.1730.00024 hafter surgery3.060.444.330.894.5530.00048 hafter surgery2.190.753.250.454.6500.000Exercise VAS score6 hafter surgery3.380.725.080.795.9560.00024 hafter surgery3.750.775.830.727.2640.00048 hafter surgery2.500.523.920.795.7250.000Tab.7Ramsay sedation score and QoR15GroupObservation groupControl grouptPn1612Ramsay(score)2.310.482.330.500.1130.911QoR15(score)119.383.46106.673.639.4210.0002.4焦虑评分两组妊娠患者术前、术后心理状况评估采用焦虑自评量表，观察组术后SAS评分低于对照组，且低于术前SAS评分，差异具有统计学意义（P0.05），见Tab.8。Tab.8SAS scores of the two groups on the self-rating anxiety scale(x s,score)GroupObservation groupControl grouptPn1612SASpreoperation53.003.5651.175.410.0200.321postoperation48.563.5652.084.102.4280.022t6.7341.609P0.0000.136564中国临床药理学与治疗学 2024 May;29(5)2.5满意度调查两组妊娠患者出院前进行满意度调查，观察组优于对照组，差异具有统计学意义（P0.05),but the time of getting out of bed andventilation time were shortened,the scores of non-invasive blood pressure,HR,pain and anxiety in theobservation group were lower than those in thecontrol group,and the scores of patient satisfac-tion and QoR15 in the observation group were bet-ter than those in the control group(P0.05).CON-CLUSION:The application of pneumoperitoneum-free single-hole endoscope combined with ropiva-caine local infiltration anesthesia in pregnancy withovarian tumor can reach satisfactory clinical re-sults,including reducing postoperative pain andanxiety,which is worth popularizing.KEYWORDSsingle-hole laparoscopy;pneumoperi-toneum-free;ropivacaine;pregnancy;ovarian tu-mor568