| Research BackgroundGastroduodenal perforation is a common surgical emergency, which has acut e onset and rapid progression, usually suffered in severe and complicated clinical si tuations. In severe cases, it can cause septic shock, even death. Exploratory lapar otomymy and operation of perforation repair are traditional therapies of Gastr oduodenal perforation. With the development of laparoscopic technique, laparos copic neoplasty in gastroduodenal perforation is used widely.In the past, four-hole method is used in laparoscopic neoplasty in gastroduodenal perforation m ost. But for now, three-hole method is reported Successively. In the research, w e selected 72 patients of gastroduodenal perforation in our hospital from Janua ry 2011 to September 2012. They were randomly divided into two groups, obs ervation group and control group. By comparing the clinical data of two group s of patients, this research discusses the advantages and disadvantages of two kinds of operative methods.ObjectionTo discuss the chinical effects of four-hole method and three-hole method of laparoscopic neoplasty in gastroduodenal perforation.Method72 patients of gastroduodenal perforation were randomly divided into two groups. The three-hole method of laparoscopic neoplasty in gastroduodenal perf oration was used in observation group and four-hole method of laparoscopic ne oplasty in gastroduodenal perforation was used in control group. There are 36 patients in observation group and 36 patients in control group. Operative time, blood loss, postoperative intestinal exhaust time, hospital stay, postoperative co mplications and conversion to laparotomy rate were compared between the two groups. Taking the data to statistical analysis by SPSS.16 statistical software and Comparing the difference of index between two groups.1.1 General InformationWe selected 72 patients of gastroduodenal perforation in our hospital fro m January 2011 to September 2012. They were randomly divided into two gro ups, observation group and control group, in accordance with the random numb er table.The three-hole method of laparoscopic neoplasty in gastroduodenal per foration was used in observation group and four-hole method of laparoscopic n eoplasty in gastroduodenal perforation was used in control group. There were 36 patients in control group, including 33male,3 female, age from 16 to 87, average age48.3±19.0,9 cases of gastric perforation,27 cases of duodenuml perforation. There were 36 patients in observation group, including 31 male,5 f emale, age from 13 to 88, average age51.3±18.0,10 cases of gastric perforati on,26 cases of duodenuml perforation. Comparing Two groups of patients wit h gender, age, symptoms such as general Data, there was no statistically signi ficant difference between two groups. Data are comparable. (P>0.05)1.2 grouping criteria①The patient was diagnosed with gastroduodenal perforation before operat ion by X-ray examination showing subdiaphragmatic free air.② General case is go od. There was no serious systemic diseases and severe cardiopulmonary dysfun ction. The patient can tolerated laparoscopic neoplasty in gastroduodenal perfor ation. ③ime of Perforation was not more than 48 hours. And the patient has no complication such as septic shock.④ Perforation was in anterior gastric wall or anterior duodenal bulb wall, and its diameter was 1 cm or less. ⑤The p atient has no Possibility of complication such as pyloric obstruction, massive h emorrhage, and canceration⑥ No history of surgery of epigastrium Exclusion criteria①The patients who Merged serious cardio-cerebral and pulmonary diseas es lung cannot accepted the intubation anesthesia.②The severe patients with th e weak body situation merged bleeding, shock, severe water and electrolyte bala nce disorder, and multiple organ dysfunction.③There was another contraindicati on in laparoscopic surgery. ④The patients might have widely abdominal adhesi ons or severe abdominal adhesions who had a complex history of abdominal s urgery.⑤Perforation was in gastroduodenal paries posterior. ⑥The patients were serious abdominal infection and anatomic structure of nidus was disord and S welling deformation which was difficult to be exposed.1.3 Method of operationWith general anesthesia with endotracheal intubatio, position was the head higher and the feet lower. Sliced through the skin under the navel 1cm. Placed pneumoperitoneum needle, had pneumoperitoneum with CO2 maintaining of a bdominal pressure 10-12mmHg, placed 10mm trocar and 30°laparoscopic lens. Observation group:Placed 10mm cannula 3cm under the intersection of left c ollarbone midline and costal margin. That was the The main operation hole in right hand side. According to difference of position of perforation, the positi on of auxiliary operation hole in left hand side was different. We could place 5mm cannula 3cm under intersection of the right clavicle middle line or right axillary front line and costal margin. Control group:Placed 10mm cannula 3 cm under the intersection of left axillary front line intersection and costal mar gin. That was the The main operation hole in right hand side. Placed 5mm c annula in the intersection of left clavicle middle line and Umbilical horizontal line. That was the the first auxiliary operation hole. Placed the other 5mm ca nnula 3cm under the intersection of the right axillary front line intersection an d costal margin or below the xiphoid process. That was the the second auxilia ry operation hole. Each operation hole can be made according to the different perforation position and actual requirement to adjust up and down. Sucked out the effusion in abdominal cavity and sended for germiculture. After abdominal exploration, we separated adhesions around the perforation and find it in attac hment sites of pus mosses. If it was gastric perforation, some tissue around it was sended for pathological examination to eliminate malignancy routinely. A s ingle-layer interrupted suture with 1-3 stitches were made along gastroduodenal 1 ongitudinal axis by 3-0 PGA Resorba. Tied a knot. And then the knot was cov ered and fixed by omentum majus around it. Abdominal and pelvic cavity was washed by 6000-10000ml normal saline to which was clean. Drainage tube wa s placed in lesser omentum hole, and the seepage was drainaged from xiphoid process or right costal margin incision. The abdominal cavity with severe infec tion was drainaged by several drainage tubes from both sides under the diaphr agm and the pelvic cavity. Finally pneumoperitoneum was removed. Cannula w as pulled out. Drainage tube was fixed. Incision was sutured or not. The patie nts in both groups were treated by gastrointestinal decompression, anti-inflamm ation and relieving hyperacidity. The patients took antiacid andpeptic ulcer drugs after leaving hospital for 2 months regularly.1.4 observed indicatorOperative time, blood loss, postoperative intestinal exhaust time, hospital stay, postoperative complications and conversion to laparotomy rate were comp ared between the two groups.1.5 statistic analysisSPSS 16.0 statistical software was used to analysis data. Each data was t o be normality tested (Shapiro-wilk). If the data accorded with normal distr ibution, measurement data was signified by mean (±) standard deviation (x±s). T test was adopted to measure the data of two groups. If the data did not accord with normal distribution, measurement data was signified by median (th e upper and lower quartiles). Non-parametric test was adopted to compare the m easuring data of two groups (Mann-Whitney U test).X2 test was adopted to c ompare the count data of two groups. If it showed (P< 0.05), it means that difference was statistically significant.ResultsThe operative time of observation group were significantly longer than co ntrol group. The difference was statistically significant (P<0.05). The blood los s, postoperative intestinal exhaust time, hospital stay of observation group wer e superior to control group. The difference was statistically significant (P<0.05).The postoperative complications and conversion to laparotomy rate were not showed significant differences between the two groups (P>0.05).2.1 operation indicatorThe operative time of observation group were significantly longer than co ntrol group. The difference was statistically significant (P<0.05). The blood los s, postoperative intestinal exhaust time, hospital stay of observation group wer e superior to control group. The difference was statistically significant (P<0.0 5).2.2 The postoperative complications and conversion to laparotomy rate2 cases of postoperative incision infection happened in observation group The incidence of complication was 5.6%. The control group had 1 case of inc ision infection,1 case of pneumonia, the incidence of complications was 5.6%. The postoperative complications and conversion to laparotomy rate were not s howed significant differences between the two groups (P>0.05).Observation gr oup and control group had 1 case of conversion to laparotomy each, and had no death.DiscussionGastroduodenal perforation was a common surgical emergency, which was cc ounted for about 15% of hospitalized cases of ulcer and about 30% of the cas es of surgical treatmentm. The traditional treatment of gastroduodenal ulcer per foration was subtotal gastrectomy, in order to achieve the purpose of a radica 1 cure. in recent years, due to the high efficiency for the treatment of antiacid a ndpeptic ulcer drugs, it achieved good effect by taking them after neoplasty in g astroduodenal perforation. The purposes of Laparoscopic neoplasty and laparoto my are to repair gastroduodenal perforation. Laparotomy requires large abdomi nal incision. Patients were injuried more and postoperative complications were more. Because The viewing Angle of laparoscope was adjustable, surgery fi eld of laparoscopic neoplasty was more extensive and clearer than laparotomy Laparoscopic neoplasty was conducive to suck effusion and clean the abdomin al cavity thoroughly. Laparoscopic neoplasty significantly reduced the formation of abdominal residual infection and abscess postoperatively. The patients injur ed less and suffered less pain. Patients had earlier ambulation postoperatively, and which promoted haemal circulation. It reduced the occurrence of postoperat ive pulmonary infection thereby. Gloves were avoid to contact with abdominal cavity directly by Laparoscopic neoplasty. Gastrointestinal stimulation was sligh ter. It contributed to the quick recovery of gastrointestinal function. The incidenc e of postoperative incision adhesion and intestinal adhesion was lower. Four-hole or five-hole method was used to operate in Conventional laparoscopi c gastroduodenal ulcer perforation usually. Some surgeons liked to take three-hole method,too. Comepared three-hole method and Four-hole or five-hole meth od, three-hole method reduce the 1～2 piercing holes, injured less and caused less pain. It was accepted by patients easilier.The method of randomized controlled clinical trials was adopted in this st udy. Compare the curative effect of three hole method and the four hole meth od. The method of laparoscopic neoplasty in gastroduodenal perforation has not been standardized. The reason of that was the randomized controlled clinical t rials of comparing three-hole method and four-hole method about curative eff ect, complications and adverse reaction have not been carried out. We did not know which approach was better. To explore the advantages and disadvantages of both, we need convincing clinical trials. This experiment proved that the b lood loss, postoperative intestinal exhaust time, hospital stay of observation gr oup were superior to control group through rigorous randomized controlled clin ical trials. The result came from clinical trials based evidence-based medicine. I t was promising. It was worth popularizing widely in clinic.Three-hole method and the four-hole method had certain differences in op eration, not only one hole. There were certain differences between three-hole method and the four-hole method in patients with surgical position, the positio n of the operator, specific operation steps and intraoperation between aide and assist. Whether the performer usded three-hole method or four-hole method, it depended on state of the illness, intra-abdominal pollution, especially in the habi t of operator. The findings of this study suggest that the blood loss, postoperative intestinal exhaust time, hospital stay of observation group were superior to co ntrol group. The difference was statistically significant (P<0.05). Although three hole method of operation reduced the wound, it does increase the difficulty o f intraoperative exposure of nidus.To a certain extent, it increased the operation risk.The operative time of observation group were significantly longer than co ntrol group. The difference was statistically significant (P<0.05).There were 3 cases of wound infection in this experiment. In addition to 1 cases of wound infection after conversion to laparotomy in the observation group, the rest of the two cases showed that the punctures which the drainage tubes was in were infectious. Therefore, we should pay close attention to whet her we placed the drainage tube during operation and how long it should stay. The author thinks that if the case was that the abdominal cavity was fully fl ushed, the contamination was all washed away, and suture techniques were inf allible, we can not place the drainage tubes. If the operator was not sure the suture was perfect, or severe contamination in abdominal cavity, we can consid er to put drainage tube. But we should remove the drainage tube in time to re duce the incidence of infection.There was 1 cases of conversion to laparotomy in both groups in this experiment.The reason was severe contamination in abdominal cavity.After exposure,it was found that the tissue surround the perforation was edema. Quality of the tissue was very crisp. Under the laparoscope, suture conditions were very poor. After conversion to laparotomy, the patients were cured successfully. Therefore, the author thinks that as long as the position of the holes were correct, it was not difficult to placed the equipment to complete the suture and ligation, flushing, suction and placing drainage tubes by three-hole method. It was not different to get clarity of nidus under laparoscope between three-hole method and four-hole method. But if it was difficult to expose and operate, we should use four-hole method or conversion to laparotomy. We should not ignore the safety of operation to pursue to less hole simply.Conclusion1. Laparoscopic neoplasty in gastroduodenal perforation with four-hole method and three-hole method both were minimally invasive surgeries with less trauma and fast recovery.2. Four-hole method was easier operation and shorter operative time than three-hole method, for beginners as well as more complex cases.3. We gave preference to three hole method compared with the four hole method in blood loss, postoperative recovery time having an advantage. |
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