肥胖对后腹腔镜手术患者腹内压的影响

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摘要目的分析肥胖对后腹腔镜手术患者腹内压（IAP）的影响。方法 2018年10月—2019年7月，于山西医科大学第一医院行后腹腔镜下部分肾切除术的患者中，根据体重指数（BMI）水平分为肥胖组和正常组，每组各30例。两组患者均采取经后腹腔入路的方式以及全静脉麻醉维持。分别测量麻醉后仰卧位（T）、气腹前侧卧位（T0）、气腹后30 min（T1）、气腹后60 min（T2）、气腹后90 min（T3）及气腹结束后10 min（T4）的IAP。分别记录T、T0、T1、T2、T3、T4时点平均动脉压（MAP）、气道压（Peak）、氧合指数（PaO2/FiO2）、桡动脉血PH值和桡动脉血乳酸值（Lac）。结果两组患者IAP时间、组间及交互作用比较，差异有统计学意义（P ＜ 0.05）。其中，T0时点高于T时点，T1～T3时点高于T0时点，T4时点低于T1～T3时点；肥胖组IAP各时点高于同期正常组，差异有统计学意义（P ＜ 0.05）。两组患者组间MAP水平比较，差异有统计学意义（P ＜ 0.05）。两组患者Peak、PaO2/FiO2、血PH、血Lac时间、组间及交互作用比较，差异有统计学意义（P ＜ 0.05）。其中，肥胖组各时点Peak水平高于正常组，且两组患者T1～T3高于T0、T4时点，差异有统计学意义（P ＜ 0.05）；肥胖组T3、T4时点PaO2/FiO2低于正常组，且T1～T4时点低于T0时点，T3、T4时点低于T1时点，T4时点低于T2时点，正常组T2～T4低于T0时点，T3、T4低于T1时点，T4时点低于T2时点，差异有统计学意义（P ＜ 0.05）；肥胖组T3、T4时点血PH低于正常组，且T2～T4时点低于T0时点，T3、T4时点低于T1、T2时点，正常组T2、T3时点低于T0时点，T3时点低于T1时点，差异有统计学意义（P ＜ 0.05）；肥胖组血Lac水平T3、T4时点高于对照组，且两组患者T2～T4时点高于T0时点，T3、T4时点高于T1时点、T4时点高于T2时点，差异有统计学意义（P ＜ 0.05）。结论肥胖患者在行后腹腔镜手术时IAP会进一步升高，甚至超出气腹设定压力，且更容易发生气道压升高、氧合指数降低以及酸碱失衡。对于肥胖患者不能简单的将IAP等同于气腹压，应加强术中监测，必要时可监测IAP。

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	王喆1 吕洁萍2

关键词 ：后腹腔镜手术, 肥胖, 腹内压, 腹内高压

Abstract：Objective To analyze the influence of obesity on intra-abdominal pressure (IAP) of patients undergoing retroperitoneal laparoscopic surgery. Methods From October 2018 to July 2019, patients who underwent retroperitoneal partial nephrectomy at the First Hospital of Shanxi Medical University were divided into obese group and normal group according to their body mass index (BMI) level, with 30 cases in each group. The patients in both groups were maintained by retroperitoneal approach and total intravenous anesthesia. The IAP levels of supine position after anesthesia (T), the anterior and lateral position of the pneumoperitoneum (T0), 30 min after the pneumoperitoneum (T1), 60 min after the pneumoperitoneum (T2), 90 min after the pneumoperitoneum (T3), and the end of the pneumoperitoneum after 10 min (T4) were measured. The mean arterial pressure (MAP), airway pressure (Peak), oxygenation index (PaO2/FiO2), radial artery blood pH value and radial artery blood lactic acid value (Lac) at T, T0, T1, T2, T3, and T4 were recorded respectively. Results There were statistically significant differences of IAP levels in time, between groups and the interaction between the two groups (P ＜ 0.05). Among them, T0 time point was higher than T time point, T1-T3 time points were higher than T0 time point, T4 time point was lower than T1-T3 time points; IAP levels of obesity group was higher than that of normal group at each time point, and the differences were statistically significant (P ＜ 0.05). The difference between the two groups of MAP levels were statistically significant (P ＜ 0.05). The differences in time, inter-group and interaction of Peak, PaO2/FiO2, blood pH, blood Lac between the two groups were statistically significant (P ＜ 0.05). Among them, the Peak levels of the obesity group was higher than that of the normal group at each time point, while the T1-T3 time points of the two groups were higher than the T0 and T4 time points, and the differences were statistically significant (P ＜ 0.05); PaO2/FiO2 of obesity group at the T3 and T4 time points were lower than that of normal group, while T1-T4 time points were lower than T0, T3 and T4 time points were lower than T1 time point, T4 time point was lower than T2 time point, while T2-T4 time points of normal group were lower than T0 and T3 time points, T4 time point was lower than T1 time point, while T4 time point was lower than T2 time point, and the differences were statistically significant (P ＜ 0.05); the blood pH at T3 and T4 points in the obese group were lower than the normal group, while T2-T4 time points were lower than T0 time points, T3 and T4 time points were lower than T1 and T2 time points, while T2 and T3 time points of normal group were lower than T0 time point, T3 time point was lower than T1 time point, and the differences were statistically significant (P ＜ 0.05); the levels of blood Lac at T3 and T4 time points of obesity group were higher than those of control group, while the two groups at T2-T4 time points were higher than T0 time point, T3 and T4 time points were higher than T1 time point, while T4 time point was higher than T2 time point, and the differences were statistically significant (P ＜ 0.05). Conclusion Obese patients will further increase the IAP during retroperitoneal laparoscopic surgery, even exceeding the set pressure of the pneumoperitoneum, and are more likely to have increased airway pressure, decreased oxygenation index, and acid-base imbalance. For obese patients, IAP can not be simply equated with pneumoperitoneal pressure. Intraoperative monitoring should be strengthened, and IAP can be monitored if necessary.

Key words： Retroperitoneal laparoscopic surgery Obesity Intra-abdominal pressure Intra-abdominal hypertension

基金资助:山西省应用基础项目（201601D102068）。

通讯作者: 吕洁萍（1971.10-），女，硕士，主任医师；研究方向：临床麻醉与技能。

作者简介: 王喆（1994.11-），女，山西医科大学麻醉学院2017级麻醉学专业在读硕士研究生；研究方向：临床麻醉与技能。

引用本文:

王喆1 吕洁萍2. 肥胖对后腹腔镜手术患者腹内压的影响[J]. 中国医药导报, 2020, 17(25): 87-91.
WANG Zhe1 LYU Jieping2. Influence of obesity on intra-abdominal pressure of patients undergoing retroperitoneal laparoscopic surgery. 中国医药导报, 2020, 17(25): 87-91.

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http://www.yiyaodaobao.com.cn/CN/ 或 http://www.yiyaodaobao.com.cn/CN/Y2020/V17/I25/87

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