腹腔鏡電燒手術造成的器官損傷

Electrosurgical Injuries in Laparoscopy

腹腔鏡已被廣泛應用於婦科疾病的診斷及治療。手術中可能因直接或電熱效應造成損傷，如未能及時察覺則可能造成嚴重傷害或甚至死亡。本文報告過去3年間在台南市立醫院的223例腹腔鏡手術當中，發生6例器官損傷的經驗。其中有膀胱損傷4例，前3例在術中及時發現並加以修補，另1例則因術中未察覺而在術後2週造成膀胱陰道廔管，而後以腹式廔管切除術而治癒。病理檢查發現組織中少有白血球浸潤及微小血管的增生。另有2例具有不同臨床及病理學表現的腸道損傷，皆未在術中察覺。其中l例於術後10天發現有血便現象，以大腸鏡檢查發現有直腸潰瘍，病理切片檢查顯示局部的白血球浸潤但未有微小血管的增生。此病例最後接受大腸造口術治癒。腸道損傷另一個案則於術後隔日即有腹部不適現象，而需小腸局部切除及吻合術等治療。病理學檢查顯示相當程度的白血球浸潤及微小血管的明顯增生。基於上述的臨床及病理發現，我們認為造成膀胱損傷導致廔管的個案是因電熱損傷引起，而兩個腸道損傷則分別因為電熱損傷及直接損傷所導致。本文結果也顯示臨床病狀及病理學發現可用於區別因電熱或直接引起的器官損傷。

This is a retrospective study, based on review from medical records, to report our experience on the electrosurgical injuries that were related to the laparoscopic procedures. Also, we correlate the clinical manifestations with the histopathologic findings of traumatic and electro-thermal injury.From July 1994 through September 1998, there were six cases of electrosurgical injuries among 223 women undergoing laparoscopic surgery at Tainan Municipal Hospital.Urinary bladder injuries occurred in 4 cases. The injuries in three patients were recognized intraoperatively and were successfully repaired; the other patient with unrecognized bladder injury developed vesicovaginal fistula two weeks after laparoscopic surgery, and was later treated by fistulectomy. The pathologic examination showed absence of either white-cell infiltration or capillary ingrowth in the surgical specimen. It is note worthy that two cases of inadvertent bowel injuries, which had distinct clinical and pathologic manifestations, were observed. One patient presented with bloody stool 10 days following the laparoscopic procedure, and colonoscopic examination revealed a rectal ulcer. The pathologic results of biopsy showed focal white-cell infiltration and absence of capillary proliferation. This patient underwent colostomy for definitive treatment. The other patient presented with symptoms of abdominal discomfort one day following laparoscopy. Segmental resection of ileum with end-to-end anastomosis was performed. Pathological examination on the resected ileum revealed intestinal perforation with inflammatory-cell infiltration and abundant capillary ingrowth.Our data suggest that the clinicopathologic characteristics may be helpful in distinguishing electro-thermal from traumatic injuries. Furthermore, timely detection of electrosurgical injuries intraoperatively will substantially reduce the morbidity of the patients.