自腹腔镜问世以来，腹腔镜手术所特有的戳孔并发症也随之出现，其中戳孔出血就是其特有并发症之一。

　　Since the advent of laparoscopy, the special perforation complications of laparoscopic surgery have also appeared, among which perforation bleeding is one of its unique complications.

　　戳孔出血的大部分原因是由于气腹针或 Trocar 穿刺损伤腹壁血管引起的，戳孔出血在外科腹腔镜手术中发生率约为 0.85%。

　　Most of the bleeding was caused by the injury of abdominal vessels by pneumoperitoneum needle or trocar puncture. The incidence of bleeding was about 0.85% in laparoscopic surgery.

　　戳孔出血大多数发生于手术的开始，它的发生不仅会使术者完成手术的信心受到打击，而且它还会延长手术时间，严重者甚会导致整台腹腔镜手术的失败。

　　Most of the perforation bleeding occurs at the beginning of the operation. Its occurrence will not only make the operator's confidence to complete the operation be hit, but also prolong the operation time, even lead to the failure of the whole laparoscopic operation.

　　那么，对于这个如此痛心疾首的问题，我们该如何处理呢？答案就在本文。

　　So, how can we deal with such a painful problem? The answer is in this article.

　　戳孔出血的常见原因

　　Common causes of bleeding from punctures

　　我们先对腹壁戳孔出血的原因分析一下，一般有以下几点：

　　First of all, we will analyze the causes of abdominal perforation bleeding, generally including the following points:

　　1) 腹壁血管丰富，彼此吻合成网，穿刺操作时有一定的盲目性，容易导致腹壁血管的损伤出血；

　　1) There are abundant blood vessels in the abdominal wall, anastomosing each other to form a network, and there is certain blindness in the puncture operation, which is easy to cause the injury and bleeding of the blood vessels in the abdominal wall;

　　2) 标本取出时，特别是体积较大的标本，盲目的扩张或用锐器切开穿刺孔，易损伤腹壁血管 ；

　　2) When the specimen is taken out, especially the larger specimen, it is easy to damage the abdominal wall blood vessels by blind expansion or cutting through the puncture holes with sharp tools;

　　3) 穿刺方向未垂直于腹壁，斜向穿刺腹壁的路径延长，容易损伤腹壁血管；

　　3) The puncture direction is not perpendicular to the abdominal wall, and the oblique puncture path is prolonged, which is easy to damage the blood vessels of the abdominal wall;

　　4) 肝硬化静脉高压造成腹壁侧支循环开放，凝血功能差等。

　　4) Cirrhotic venous hypertension results in the opening of collateral circulation and poor coagulation.

　　戳孔出血的预防措施

　　Preventive measures of bleeding from puncturing hole

　　对于腹壁戳孔出血的原因我们大概了解了，那我们该如何预防呢？

　　We have a general understanding of the causes of abdominal bleeding, so how can we prevent it?

　　腹腔镜戳孔出血的预防措施：

　　The preventive measures of laparoscopic perforation bleeding:

　　trocar 口出血的主要原因是腹壁血管损伤，多见于侧腹部戳孔，也见于脐周 trocar 口。

　　The main cause of bleeding in trocar mouth is the injury of blood vessels in the abdominal wall, which is often seen in the puncture hole in the side abdomen and also in the trocar mouth around the umbilicus.

　　对于脐周的戳孔我们可以采取开放法来建立气腹避免戳孔出血的发生；侧腹部戳孔出血通常是由于术者的麻痹大意损伤了腹壁下动脉引起。

　　We can establish pneumoperitoneum by opening the puncture hole around the umbilicus to avoid the occurrence of puncture hole bleeding. The puncture hole bleeding in the lateral abdomen is usually caused by the injury of inferior abdominal artery by the operator's numbness.

　　在这种情况下我们通常可以采用黎建华等（详见参考文献 5）介绍的透照法来避开腹壁血管网，从而预防戳孔出血。

　　In this case, we can usually use the transillumination method introduced by Li Jianhua et al. (see reference 5 for details) to avoid the abdominal vascular network, so as to prevent the perforation bleeding.

　　但对于腹壁肥厚病人或损伤深层血管出血的病人，此方法就显得微乎其微了，这时要想避免戳孔出血，必须要求术者熟悉常见腹壁血管的走行，尤其是腹壁动脉血管的走行，该点也是预防穿刺时损伤腹壁血管的关键所在。

　　But for the patients with abdominal wall hypertrophy or deep blood vessel bleeding, this method is very small. In order to avoid puncture bleeding, the operator must be familiar with the common abdominal wall blood vessels, especially the abdominal wall artery vessels. This point is also the key to prevent the injury of abdominal wall vessels during puncture.

　　那么常见的腹壁血管有哪些，走行又是如何的呢？我们以脐水平面为界限，将腹壁血管分为脐上、下两个区域，分别简介如下：

　　So what are the common abdominal blood vessels, and how are they going? Taking the horizontal plane of the umbilicus as the boundary, we divide the blood vessels of the abdominal wall into the upper and the lower regions of the umbilicus

　　A. 脐上

　　A. Supraumbilical

　　脐上的动脉又分为浅、深两层。

　　The artery on the umbilicus is divided into two layers: shallow and deep.

　　浅层动脉大都来源于肋间血管发出的细小分支。

　　Most of the superficial arteries originate from the small branches of intercostal vessels.

　　而深层主要有两条，腹壁上动脉及下位肋间、肋下动脉。腹壁上动脉是发自于胸廓内动脉，走行于腹直肌与腹直肌鞘后层之间，供给腹直肌，并穿过腹直肌及前鞘腹前壁皮下，与腹壁下动脉分支在脐平面相互吻合。

　　In the deep layer, there are two main arteries: the superior epigastric artery and the inferior intercostal and subcostal artery. The superior epigastric artery originates from the internal thoracic artery, runs between the rectus abdominis and the posterior layer of the sheath of the rectus abdominis, supplies the rectus abdominis, passes through the rectus abdominis and the anterior sheath to the hypodermis of the anterior epigastric wall, and coincides with the branches of the inferior epigastric artery in the umbilical plane.

　　B. 脐下

　　B. Subumbilicus

　　脐下腹壁动脉同脐上一样分为深、浅两层。

　　The artery of the hypoumbilical abdominal wall is divided into deep and shallow layers as well as that of the supraumbilical.

　　浅动脉层主要有两条，分别是腹壁浅动脉及旋髂浅动脉。腹壁浅动脉越腹股沟韧带中内 1/3 向脐部走行；旋髂浅动脉起始部常较腹壁浅动脉高出 1 cm，在浅筋膜浅深两层之间向髂前上棘走行。

　　There are two main arteries in the superficial arterial layer: the superficial abdominal artery and the superficial circumflex iliac artery. The origin of the superficial circumflex iliac artery is usually 1 cm higher than that of the superficial abdominal artery, and runs between the superficial and deep layers of the superficial fascia to the anterior superior iliac spine.

　　深层也有两条主要的血管，分别是腹壁下动脉及旋髂深动脉。腹壁下动脉是近腹股沟韧带中点稍内侧处发自髂外动脉，穿腹横筋膜上行于腹直肌与腹直肌鞘后层之间，脐平面附近与腹壁上动脉吻合；

　　There are two main vessels in the deep layer, the inferior abdominal artery and the deep circumflex iliac artery. The inferior epigastric artery originates from the external iliac artery at the medial point of the inguinal ligament, and runs up between the rectus abdominis and the posterior sheath of the rectus abdominis through the transverse abdominal fascia, and anastomoses with the superior epigastric artery near the umbilical plane;

　　旋髂深动脉与腹壁下动脉起自同一水平，在腹膜外组织内沿着腹股沟外侧半的深面斜向外上方，行向髂前上棘内侧，髂肌和髂骨等。

　　The deep circumflex iliac artery and inferior epigastric artery originate from the same level. In the extraperitoneal tissue, they incline outwards and upward along the deep side of the lateral half of the groin, to the medial side of the anterior superior iliac spine, to the ilium muscle and ilium bone.

　　血管损伤的处理策略

　　Management strategy of vascular injury

　　在现实中，我们虽然对腹壁血管的走行已经非常熟悉了，但是还有一部分人腹壁血管走行存在变异，导致我们在穿刺中不幸地损伤了腹壁血管，这时我们该怎么办？放弃腹腔镜手术选择传统的开腹吗？

　　In reality, although we are very familiar with the course of the abdominal wall vessels, there are still some people with the variation of the course of the abdominal wall vessels, which leads to the unfortunate injury of the abdominal wall vessels during the puncture. What should we do? Give up laparoscopic surgery and choose traditional open surgery?

　　答案是否定的。因为腹壁的戳孔出血一般都是损伤腹壁的小血管，它不同于 trocar 损伤腹腔内大血管（如肠系膜上动脉、腹主动脉、下腔静脉、髂血管）那样来势凶险，处理不及时患者就危在旦夕；

　　The answer is No. Because the puncture hemorrhage of the abdominal wall is usually the small blood vessels which damage the abdominal wall, it is different from the trocar which damages the large blood vessels in the abdominal cavity (such as the superior mesenteric artery, the abdominal aorta, the inferior vena cava and the iliac blood vessels), so it is dangerous to deal with the patients in time;

　　腹壁小血管的损伤没有那么凶险，允许我们从容不迫的处理，如果处理得当能使我们的腹腔镜手术如期地进行下去。

　　The injury of the small blood vessels in the abdominal wall is not so dangerous, which allows us to deal with it calmly. If we deal with it properly, our laparoscopic operation can go on as scheduled.

　　那么对于 trocar 引起的腹壁小血管损伤我们该如何处理呢？有如下几种方法：

　　So what should we do about the injury of small blood vessels in abdominal wall caused by trocar? There are several methods:

　　1) 从外面直接压迫，这时需要一些耐心，压迫少 5 分钟！期间切忌每隔 5 秒钟就掀开来瞥一眼；

　　1) Direct pressure from outside, at this time need some patience, pressure at least 5 minutes! Do not open it every 5 seconds to catch a glimpse;

　　2) 压迫止不住血的戳孔可以拔出 trocar 找到出血点，通过结扎、缝合 、电凝等技术将其止住；

　　2) Trocar can be pulled out to find the bleeding point by pressing the puncture hole which can not stop the blood, and it can be stopped by ligation, suture, electrocoagulation and other technologies;

　　3) 从里面压迫，方法是把 Foley 导尿管经 trocar 孔插入腹腔，充气向后拽紧尿管；

　　3) The method of pressing is to insert Foley catheter into abdominal cavity through trocar hole, and pull the catheter tightly after inflation;

　　4) 在出血的动脉处通过腹壁缝合止血，这需要在腹腔镜引导下借助缝合引导器进行。

　　4) Hemostasis is achieved by abdominal wall suture at the bleeding artery, which needs to be performed under the guidance of laparoscope with the aid of suture guide device.

　　结 束 语

　　Conclusion

　　腹腔镜技术在我国基层医院得到了很好的普及，一台腹腔镜手术成功与否不仅取决于腹腔内操作的情况，而且还包括进入腹腔之前准备，如腹腔穿刺。

　　Laparoscopic technology has been widely used in primary hospitals in China. The success of a laparoscopic operation depends not only on the operation in the abdominal cavity, but also on the preparation before entering the abdominal cavity, such as abdominal puncture.

　　成功的腹腔穿刺有利于手术的顺利进行，不成功的腹腔穿刺不仅能影响手术完成的进度，而且严重者能够导致整台腹腔镜手术的失败。所以对于腹腔镜技术日益成熟的外科医生们，应该更加关注戳孔出血问题，提高警惕、避免麻痹大意，从根源上预防戳孔出血发生。

　　Successful abdominal puncture is conducive to the smooth operation. Unsuccessful abdominal puncture can not only affect the progress of the operation, but also lead to the failure of the whole laparoscopic operation. Therefore, surgeons with more and more mature laparoscopic technology should pay more attention to the problem of perforation bleeding, improve their vigilance, avoid numbness and carelessness, and prevent the occurrence of perforation bleeding from the root.