2017120840 护理学院 张笑倩
摘 肩痛腹腔镜胆囊切术常见发症目前发生机制尚明确推测发生原碳酸膈神直接刺激气腹张力膈肌牵拉作发生肩痛危险素包括患者体位术持续时间体素等效防治措施降低气腹压力排出气腹残余CO2减少CO2吸收区域神阻滞等方法均存足争议腹腔镜术肩痛需进步研究期够找更加简单效方法减少发生率减轻严重程度
关键词 腹腔镜胆囊切术肩痛防治文献综述
The Prevention and Therapy of Shouder Pain after Laparoscopic CholecystectomyA Reveiw
AbstractPostlaparoscopic shoulder pain frequently follows a laparoscopic cholecystectomy
The mechanism of the shoulder pain is uncertain which may probably include the irritation or injury of the phrenic nerve by the CO2 pneumoperitoneum or the overstretching of the superior hepatic ligaments due to CO2 insufflationThe body positionduration of the operationthe individuality are be seen as the risk factors of the shoulder pain these yearsThen several ways have been put forward to reduce the incidence of the shouder pain after laparoscopic cholecystectomy such as using lowpressure pneumoperitoneum Draining residual intraperitoneal CO2reducing the absorbtion of CO2 blocking the phrenic nerve and so onHowevereach of the way is remain controversial which reminds us that more attention should been paid to the shouler pain after the laparoscopic cholecystectomy to find a better way to solve it
Key words laparoscopic cholecystectomy shouder pain prevention and therapy reveiw
腹腔镜胆囊切术康复速度快住院时间短等优势床广泛应然开腹手术相腹腔镜术疼痛轻持续时间短极少开腹手术存肩痛成影响腹腔镜术患者康复常见发症[1]报道指出腹腔镜胆囊切术肩痛发生率2180[2]成困扰患者术舒适素成床迫切需解决问题文旨腹腔镜胆囊切术肩痛防治措施进行综述更预防腹腔镜胆囊切术肩痛发生提供
1 肩痛发生机制
关腹腔镜胆囊切术肩痛发生机制目前尚清楚现广泛接受两种
11 碳酸膈神直接刺激作
肩部疼痛解剖学基础支配膈神肩部皮肤神源性膈神受刺激时会反射性引起肩部疼痛腹腔镜程中需建立气腹般CO2气体术腹腔CO2残留时积聚腹腔中CO2水作生成碳酸膈神着直接刺激作麻醉作消失便出现肩痛现象[3]
12 气腹张力膈肌牵拉作
国学者王振显[4]等研究中通O2置换CO2发现肩痛发生率减轻单纯碳酸解释疼痛原作机制高气腹压膈肌作产生牵拉作造成肌纤维血断裂炎症介导子释放时分布膈肌中央部腹膜膈神受刺激产生肩痛气腹压力肩痛发生密切相关研究证明肩痛程度气腹作时间关[5]
2 危险素
21 体位 腹腔镜手术体位影响术肩痛发生率 [6]腹腔镜手术时肢外展会牵拉肩部肌肉韧带神引起肩痛研究发现肢外展>90°时会伤害臂丛神增肩痛发生率肢外展6070°外展8090°患者术肩痛疼痛减轻建议手术中肢外展角度应该6070°间[7]学者研究中发现术早期采头颈垫软枕抬高床头10°15°低半卧位配合呼吸训练够效减少术肩痛发生率严重程度[8]
22 手术持续时间 研究证明手术持续时间越长(>45min)术肩痛发生率疼痛程度越高[9]学者较两组手术持续时间患者术肩痛发生率时发现没统计学差异[10]手术持续时间肩痛影响需进步探究证明
23 体素 疼痛种观感受素疼痛耐受等术肩痛严重程度较影响[11]研究者提出通患者进行心理干预减轻术肩痛[12]学者研究中发现相男性患者女性术显示出更严重疼痛程度较低疼痛阈值[9]
3 防治措施
31 降低气腹压力
许研究证实标准气腹压(1216mmHg)相较低气腹压(910mmHg)降低肩痛发生频率程度较低气腹压减少膈肌牵拉减轻CO2
产生酸性环境膈肌刺激作时减少CO2残留[13]关低气腹压否会减少效手术区域影响器械操手术视野然存争议项2014年1092参者关腹腔镜胆囊切术气腹压meta分析中指出90成功低气腹压中完成手术没证够证明低气腹压安全性尤患心肺疾病患者[14]2016年篇关低气腹系统综述中提出低气腹手术优势够降低手术疼痛关安全性适性然需进步证明[15]Hemanga K [2]等研究中通手术医生调查发现低气腹压手术患者利完成手术手术时间胆囊穿孔发生率结石溢出率低气腹压标准气腹压手术中没差提出低气腹手术安全时研究指出肥胖等特殊数气腹压需充分暴露腹腔中脏器
32 排出腹腔残余CO2
研究中指出术肩痛程度残余C02量密切相关建议手术者应该排出腹腔残余C02[16]Ibrahim Atak[17]等实验中患者分两组组手术结束前动抽出膈肌气体组做动抽吸出手术结束前抽吸气体减少腹腔气体残留降低术肩痛发生率外国外许研究提出水排气法手术结束前通盐水注入排腹腔里残余CO2研究证明水排气法减轻术肩痛效果优负压吸引[18]2012年Youn Kyoung Seo[19]指出盐水输注减轻术肩痛发生率严重程度Anders Meller Donatsky[20]研究中发现生理盐水输注减轻腹腔镜胆囊切术肩痛严重程度证明减少术肩痛发生率Karim Saadati[21]实验中输注普通盐水碳酸氢钠做处理进行较发现输注普通盐水碳酸氢钠降低术肩痛程度碳酸氢钠效果优普通盐水关腹腔镜胆囊切术盐水输注排腔气体残余减轻术肩痛效性存争议需进步探究
33 减少CO2吸收
患者手术吸氧够加快氧气二氧化碳交换促进二氧化碳排降低二氧化碳膈神刺激强度降低刺激持续时间减轻术肩痛研究指出延长吸氧时间持续(10h12h)够增加吸入氧流量CO2结合减少CO2 吸收减轻术肩痛[22]甚研究提出术吸氧24h较适宜选择[23]潘晓晶[24]等研究中发现术氧疗6h10h效改善腹腔镜病术肩痛程度氧疗作会时间延长增强着时间推移病体CO2
已逐渐排出目前数观点认腹腔镜应进行持续低流量吸氧鞠富霞[25]研究中通较吸氧浓度改善腹腔镜肩痛影响中发现流量相中流量吸氧够效减轻腹腔镜术患者肩痛减少患者止痛药研究发现术第天午5Sb250ml缓慢滴注联合吸氧效减轻术肩痛程度苏够血液中CO2结合力提高加速体CO2代谢减少CO2吸收关[26]
34 区域神阻滞
肩部疼痛解剖学基础膈神锁骨神源性支配膈肌肩部皮肤神位C3CO2膈神产生刺激时便会反射性引起肩部疼痛根解剖学特点学者提出通局部麻醉药阻滞膈神减少术肩痛发生率严重程度[27]学者存疑认局部麻醉药减轻术肩痛麻醉药物会腹腔液术中洗液稀释时腹膜吸收难起防止术肩痛作[28]2015年项meta分析通39研究综合分析指出局部麻醉药物够效控制术肩痛肯定局部麻醉作[29]Myung Sub Yi[30]等研究中提出基础提出利超声引导阻滞膈神出超声引导膈神阻滞减少预防术肩痛会引起呼吸适建议超声引导膈神阻滞利床
35
研究报道脐入路单切口腹腔镜够减少术疼痛[31]2013年关单切口腹腔镜传统腹腔镜较meta分析中显示单切口腹腔镜术24时疼痛评分略低传统腹腔镜没统计学意义[32]学者提出术中温暖湿润(37℃90)CO2减轻肩痛效果然存争议[33]外采膝胸卧位[34]微波射[35]放置排气[36]等报道研究数量较少效果样需进步验证
4 结
综述腹腔镜胆囊切术住院时间短康复时间快等优势已床广泛应术肩痛发生困扰着患者床工作员解决问题国外许学者直致力术肩痛研究目前关发生机制未确切答案肩痛发生素综合作结果体位手术持续时间体素等关种素复杂性肩痛种防治方法效果研究方应该进步确定腹腔镜术肩痛机制原基础努力找简单行防治方法减轻患者腹腔镜术适促进患者康复提高医疗服务水
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