《腹腔鏡手術(shù)麻醉》課件

21世紀(jì)外科開展方向移植外科微創(chuàng)外科修復(fù)外科腫瘤的分子生物學(xué)治療偉大思想的提出-----公元前460-377提出借助某種手段窺視和檢查直腸病變Hippocrates1795年德國PhilipBozzini開創(chuàng)了診斷與治療的新天地現(xiàn)代腹腔鏡的起源1901年，德國的外科醫(yī)師Georgkelling在狗的腹腔內(nèi)插入一根膀胱鏡,并用空氣制造氣腹進(jìn)行檢查，這為腹腔鏡的起源。Georgkelling1910年瑞典斯德歌爾摩的jacobaeus首次在臨床使用腹腔鏡和胸腔鏡檢查，并將其定義為Laparoscopy。Hepublishedhisreportin?MünchenerMedizinischeWochenschrift.?HansChristianJacobaeus(1879–1937)1911年美國johnshopkins醫(yī)院的外科醫(yī)師bernhein經(jīng)腹壁的切口把直腸鏡插入腹腔，用發(fā)射光做光源。1924年美國堪薩斯的內(nèi)科醫(yī)師stone用鼻咽鏡插入狗的腹腔，并推薦用一種橡膠墊圈幫助封閉穿刺套管防止操作中漏氣。1938年匈牙利的外科醫(yī)師veress介紹了一種注氣針，可以平安地做成氣胸；在做氣腹時，可以防止針尖損傷針下的內(nèi)臟。這種平安穿刺針制作氣腹的主張被普遍接受，并沿用至今。揭開了微創(chuàng)外科開展的新紀(jì)元

BettercosmeticresultsLesspain,lessanalgesicsrequiredShorterin-hospitalstayLesscomplications(outcome?)Betterpulmonaryfunction(inparticularinobesepatients)Fastrecovery,bettercomfortCholecystectomiesinaHospital19901991199219931994199519961997200120020306090120150180210240OpenLaparoscopicCholecystectomiesinaHospital19901991199219931994199519961997200120020306090120150180210240OpenLaparoscopicOpenportion50%CholecystectomiesinaHospital19901991199219931994199519961997200120020306090120150180210240OpenLaparoscopicOpenportion33%CholecystectomiesinaHospital19901991199219931994199519961997200120020306090120150180210240OpenLaparoscopicOpenportion13%SurgeonUrologistGynecologistDiagnosticIntestinalHerniotomyLiverSpleenFundioplicationCholecystectomyEsophagusAxillarlymphonodesGastricbandingAdrenalectomyParathyreoidectomyDiagnosticNephrectomyKidneycystsProstatectomyVaricoceleLymphadenectomyTesticulardescensusDiagnosticTubarligationAdnexectomyOvarectomyLymphadenectomyEndometriosisMyomectomyAxillarlymphonodes三、對麻醉的要求與挑戰(zhàn)氣腹1.氣腫2.氣胸3.氣體栓塞4.對通氣的改變5.高碳酸血癥6.對血流動力學(xué)的反響7.局部血流動力學(xué)的影響8.心率失常9.反流誤吸10.肩部酸痛對肺功能影響OrganSystemPhysiologicEffectPotentialOutcomePulmonary?peakairwaypressure?pulmcomplianceSuperiordisplacementofdiaphragm?end-tidalCO2Barotrauma?pCO2or?pO2?pCO2or?pO2Acidosis對心血管功能影響OrganSystemPhysiologicEffectPotentialOutcomeCirculatoryDirecteffects-?CVP,CWP,SVR(afterload),MAPIndirecteffects–arteriolardilationandmyocardialdepressionIndirecteffects–sympathetics,renin-angiotensin?cardiacwork?bloodpressure?Bloodpressureandcardiacoutput?Urineoutput?體位

頭低位:↑CVPandcardiacoutputAffectpatientswithcoronaryarterydiseaseElevationintraocularvenouspressure

(worsenacuteglaucoma)IncreaseriskofgasembolismAtelectasisDecreasedFRC,totallungvolume