Cov tswv yim ua haujlwm thiab cov txheej txheem rau Veress Needle hauv ntau qhov xwm txheej

https://en.wikipedia.org/wiki/Veress_needle

Hauv kev phais laparoscopic,Veress needle insertion tsis yog nruj, "ib-size- haum-txhua" txheej txheem. Kev ntsib cov neeg mob uas muaj hnub nyoog sib txawv, lub cev muaj lub cev, thiab keeb kwm kev kho mob, tus kws phais yuav tsum ua zoo li tus kws paub txog kev txawj ntse- hloov kho cov tswv yim thiab siv ntau yam txuj ci kom ua tiav "kev nkag mus tau zoo ntawm thawj qhov kev sim, ua kom muaj kev nyab xeeb thiab kev thaj yeeb ntawm lub siab." Kab lus no tshawb txog cov tswv yim thov thiab cov txheej txheem siab heev rau kev siv Veress koob hla ntau yam xwm txheej kho mob.

I. Tus Qauv Scenario: Tus neeg mob BMI ib txwm tsis muaj kev phais ua ntej

Rau cov pab pawg neeg mob no feem ntau, kev ua haujlwm yog tus qauv.

• Nkag qhov chaw:Lub hauv paus ntawm umbilicus yog qhov nyiam xaiv. Nws yog ib qho natural 薄弱点 (tsis muaj zog taw tes) qhov twg lub plab phab ntsa yog thinnest thiab vascularity tsawg heev.
• Tus neeg mob Positioning:Supin.
• Cov txheej txheem ua haujlwm:
  1. Tsim nyog Abdominal Wall Elevation:Tus kws phais lossis tus neeg pabcuam yuav tsum tuav lub plab phab ntsa ntawm ob sab ntawm lub umbilicus lossis siv ob lub phuam clamps los nqa cov tawv nqaij cephalad. Qhov no tsim kom muaj kev nyab xeeb qhov chaw tsawg kawg yog 5-10 cm ntawm phab ntsa thiab hauv qab viscera.
  2. Insertion Angle:Tuav Veress koob ntawm a45-60-degree kaum sab xistxheeb ze rau phab ntsa plab, coj nws mus rau lub sacral promontory (ie, lub plab kab noj hniav). Tsis txhob ntsug ntsug.
  3. Slow Advancement:Ua ntej tsis tu ncua thiab maj mam nrog cov lus tsa suab. Ua tib zoo pom cov"ob pops"- thawj zaug los ntawm lub qhov quav, qhov thib ob los ntawm peritoneum. Kev nkag mus rau hauv cov kab noj hniav peritoneal yields ib qho kev xav ntawm "tsis muaj zog."
  4. Kev txheeb xyuas:​ Ua qhov hanging drop test lossis pib qis -pressure insufflation.

II. Challenge Scenario 1: Tus Neeg Mob Obese

Cov neeg mob rog rog muaj ib txheej tuab heev subcutaneous rog, qee zaum tshaj 10 cm. Qhov no tuaj yeem ua rau tus qauv- ntev Veress koob tsis txaus thiab ua kom cov lus tawm tswv yim tactile, ua rau qhov "pop" tsis meej pem.

• Kho qhov nkag Point:​ Xaiv qhov "qhov siab tshaj plaws" saum toj lossis hauv qab ntawm lub umbilicus. Qee lub sij hawm, deviating ntawm umbilicus mus rau sab ciam teb ntawm lub plab plab yog qhov tsim nyog, vim tias cov rog txheej yuav thinner nyob ntawd.
• Cov txheej txheem tshwj xeeb:
  • "Long Needle" Strategy:Siv 120 mm lossis 150 mm ntev Veress koob.
  • Lub kaum ntse ntse ntxig:Txo lub kaum sab xis (ze rau 30-45 degrees) kom nce qhov tob tob tob.
  • Qhov "Swing Test":​ Tom qab tso, maj mam rub lub koob hub sab - mus rau - sab. Yog tias intraperitoneal, lub taub yuav tsum viav vias dawb; yog embedded rau hauv cov ntaub so ntswg, txav yuav raug txwv.
  • Kev ntsuas siab:Thaum xub thawj siab insufflation yuav siab dua me ntsis (8-10 mmHg) nyob rau hauv cov neeg mob rog rog, tab sis lub siab nkhaus yuav tsum stabilize. Yog tias qhov siab tsis tu ncua siab tshaj 12 mmHg, xav tias qhov chaw tso rau hauv qhov chaw ua ntej -peritoneal.

III. Challenge Scenario 2: Cov neeg mob nrog kev phais plab ua ntej

Qhov no yog - pab pawg txaus ntshai rau Veress insertion. Adhesions tuaj yeem khi lub plab ncaj qha rau ntawm phab ntsa sab hauv plab, ua rau muaj kev sib tsoo uas tuaj yeem nkag mus.

• Xav txog contraindications:Rau cov neeg mob uas muaj ntau yam laparotomies ua ntej lossis paub txog kev ua kom zoo nkauj, xav txog kev tso tseg Veress koob kom pom zoo rau txoj kev qhib Hasson.
• Lwm qhov chaw nkag:Yog tias Veress yuav tsum tau siv, xaiv qhov chaw 远离 (nyob deb ntawm) qhov chaw phais thawj zaug.
  • Sab laug Upper Quadrant (Palmer's Point):​ Nyob 3 cm hauv qab ntawm sab laug costal margin nyob rau hauv nruab nrab -clavicular kab. Cov cheeb tsam no feem ntau muaj qhov curvature ntau dua ntawm lub plab, uas yog qhov khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob khoob.
  • Txoj Cai Upper Quadrant:Cov laj thawj zoo sib xws siv tau, tab sis yuav tsum tau saib xyuas kom tsis txhob muaj lub siab.
• Cov txheej txheem ua haujlwm:
  • "Ob-Txoj Kev Theem":Siv Veress koob txhawm rau nkag mus rau hauv lub plab phab ntsa tab sis tsis txhob maj kom insufflate. Tshem tawm cov stylet thiab hla lub catheter ntev, nyias los yog cov ntawv qhia los ntawm rab koob sheath rau hauv plab. Tom qab ntawd, dilate thiab tso thawj trocar hla cov hlau. Qhov no tso cai rau kev paub meej ntawm kev nkag mus rau peritoneal.
  • "Visual Access" Technique:​ Siv ib rab koob Veress kho qhov muag lossis ncaj qha - saib cov khoom siv kho qhov muag kom pom cov ntaub so ntswg hauv lub sijhawm tiag tiag -, zam qhov muag tsis pom kev.

IV. Tshwj xeeb Scenarios: Pediatric thiab Geriatric Patients

• Pediatric Patients:Tus cwj pwm los ntawm cov phab ntsa hauv plab nyias, me me intraperitoneal ntim, thiab lub cev sib thooj. Siv cov koob Veress luv dua (piv txwv li, 80 mm), lub kaum sab xis ntxig, thiab qis qis qis (6-8 mmHg). Qhov siab ntawm lub plab yog qhov tseem ceeb.
• Cov neeg mob Geriatric:Feem ntau tshwm sim nrog cov leeg nqaij atrophied plab thiab cov tawv nqaij elasticity tsis zoo. Qhov kev hnov ​​​​tsw ntawm kev tawm tsam thaum lub sij hawm tso tawm yog txo qis, ua rau muaj kev pheej hmoo ntau dua - nkag mus. Ua haujlwm maj mam thiab saib xyuas insufflator siab ze.

V. Advanced Techniques and Reflections

• "Mloog rau qhov chaw":Qee tus kws phais mob mloog zoo rau lub hub thaum lub sij hawm insufflation. Lub suab ntawm cov pa nkag mus rau hauv cov kab noj hniav peritoneal yog qhov txawv "hissing," tsis zoo li lub suab nrov ntawm cov pa nkag mus rau cov ntaub so ntswg subcutaneous.
• "Kev Ntsuas Dej":Txhaj me me ntawm saline rau hauv rab koob. Yog hais tias nws ntws nyob rau hauv dawb do yam tsis muaj kev tiv thaiv, lub ntsis yog yuav intraperitoneal.
• Paub Thaum Yuav Tso Tawm:Qhov txuj ci tseem ceeb tshaj plaws yog paub thaum twg yuav tsum nres. Yog tias koj tsis lees paub qhov kev tso kawm tom qab 1-2 qhov kev sim, lossis yog tias muaj qhov txawv txav tshwm sim (xws li, ntshav ntawm kev xav, tsis tu ncua siab), tso tseg qhov kev sim tam sim ntawd thiab hloov mus rau Hasson txoj kev qhib. Kev pheej hmoo nrog txoj kev tsis raug yog thawj qhov ua rau muaj teeb meem loj.

Xaus

Veress needle insertion yog ib qho kev ua tau zoo heev. Raws li cov lus hais mus,"Phau ntawv kev paub yog superficial; kev nkag siab tseeb tsuas yog los ntawm kev xyaum."Tsuas yog los ntawm kev kho mob dav dav thiab kev txhim kho cov tswv yim ntawm tus kheej rau cov neeg mob sib txawv tuaj yeem ua tus paub txog daim duab no tiag tiag, hloov Veress koob mus rau qhov ntsuas kev nyab xeeb thiab ua tau zoo hauv tus kws phais neeg txhais tes.