腹腔镜手术相关性膈肌损伤的研究进展
Research Advances in Laparoscopic Surgery-Associated Diaphragmatic Injury
DOI: 10.12677/acm.2025.15113229, PDF,   
作者: 高 萌：西安医学院第一附属医院麻醉科，陕西 西安；西安医学院研究生处，陕西 西安；宋晓阳*：西安医学院第一附属医院门诊部，陕西 西安
关键词: 腹腔镜手术；膈肌；超声检查；围术期护理；Laparoscopic Surgery； Diaphragm； Ultrasound Examination； Perioperative Care
摘要: 腹腔镜手术因其微创优势已成为腹部外科的主流术式，但其必需的非生理性气腹与体位易导致膈肌损伤，引发术后低氧血症、肩痛和肺功能不全等并发症，严重影响患者加速康复。本文系统综述该损伤的病理生理机制；综述床旁超声在量化评估膈肌功能中的应用价值，并归纳总结基于循证医学的围术期多维度膈肌保护策略，为临床防治膈肌损伤、改善患者预后提供理论依据与实践指导。
Abstract: Laparoscopic surgery has become a mainstream procedure in abdominal surgery due to its minimally invasive advantages. However, the required non-physiological pneumoperitoneum and patient positioning can easily lead to diaphragmatic injury, triggering postoperative complications such as hypoxemia, shoulder pain, and pulmonary dysfunction, which significantly impact enhanced patient recovery. This article systematically reviews the pathophysiological mechanisms of this injury, summarizes the value of bedside ultrasound in the quantitative assessment of diaphragmatic function, and synthesizes evidence-based, multi-dimensional perioperative protective strategies for the diaphragm. The aim is to provide a theoretical basis and practical guidance for the clinical prevention and management of diaphragmatic injury and for improving patient outcomes.
文章引用：高萌, 宋晓阳. 腹腔镜手术相关性膈肌损伤的研究进展[J]. 临床医学进展, 2025, 15(11): 1350-1358. https://doi.org/10.12677/acm.2025.15113229

参考文献

[1] Elias, K.M., Brindle, M.E. and Nelson, G. (2025) Enhanced Recovery after Surgery—Evidence and Practice. NEJM Evidence, 4, EVIDra2400012. [Google Scholar] [CrossRef] [PubMed]
[2] de Boer, W.S., Parlevliet, K.L., Kooistra, L.A., Koster, D., Nieuwenhuis, J.A., Edens, M.A., et al. (2025) Ultrasound as Diagnostic Tool in Diaphragm Dysfunction: A Prospective Construct Validity Study. Respiratory Medicine, 241, Article ID: 108083. [Google Scholar] [CrossRef] [PubMed]
[3] Powers, S.K. (2025) Diaphragm Function in Health and Disease. In: Ji, L.L., Ed., The Skeletal Muscle: Plasticity, Degeneration and Epigenetics, Springer, 615-630. [Google Scholar] [CrossRef] 
[4] Sun, M., Jia, R., Wang, L., Sun, D., Wei, M., Wang, T., et al. (2023) Effect of Protective Lung Ventilation on Pulmonary Complications after Laparoscopic Surgery: A Meta-Analysis of Randomized Controlled Trials. Frontiers in Medicine, 10, Article 1171760. [Google Scholar] [CrossRef] [PubMed]
[5] Lee, D.H., Song, T., Kim, K.H. and Lee, K.W. (2017) Incidence, Natural Course, and Characteristics of Postlaparoscopic Shoulder Pain. Surgical Endoscopy, 32, 160-165. [Google Scholar] [CrossRef] [PubMed]
[6] Ortenzi, M., Montori, G., Sartori, A., Balla, A., Botteri, E., Piatto, G., et al. (2022) Low-Pressure versus Standard-Pressure Pneumoperitoneum in Laparoscopic Cholecystectomy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Surgical Endoscopy, 36, 7092-7113. [Google Scholar] [CrossRef] [PubMed]
[7] Zhao, Y., Xin, W. and Luo, X. (2025) Post-Laparoscopic Shoulder Pain Management: A Narrative Review. Current Pain and Headache Reports, 29, Article No. 18. [Google Scholar] [CrossRef] [PubMed]
[8] Wahba, R.W.M., Béïque, F. and Kleiman, S.J. (1995) Cardiopulmonary Function and Laparoscopic Cholecystectomy. Canadian Journal of Anaesthesia, 42, 51-63. [Google Scholar] [CrossRef] [PubMed]
[9] Rustagi, P.S., Yadav, A. and Nellore, S.S. (2023) Ultrasonographic Evaluation of Diaphragmatic Excursion Changes after Major Laparoscopic Surgeries in the Trendelenburg Position under General Anaesthesia: A Prospective Observational Study. Indian Journal of Anaesthesia, 67, S274-S280. [Google Scholar] [CrossRef] [PubMed]
[10] Bogár, L., Domokos, K., Csontos, C. and Sütő, B. (2024) The Impact of Pneumoperitoneum on Mean Expiratory Flow Rate: Observational Insights from Patients with Healthy Lungs. Diagnostics, 14, Article 2375. [Google Scholar] [CrossRef] [PubMed]
[11] Odeberg, S., Ljungqvist, O., Svenberg, T., Gannedahl, P., Bäckdahl, M., Rosen, A.V., et al. (1994) Haemodynamic Effects of Pneumoperitoneum and the Influence of Posture during Anaesthesia for Laparoscopic Surgery. Acta Anaesthesiologica Scandinavica, 38, 276-283. [Google Scholar] [CrossRef] [PubMed]
[12] Katayama, S., Mori, K., Pradere, B., Yanagisawa, T., Mostafaei, H., Quhal, F., et al. (2021) Influence of Steep Trendelenburg Position on Postoperative Complications: A Systematic Review and Meta-Analysis. Journal of Robotic Surgery, 16, 1233-1247. [Google Scholar] [CrossRef] [PubMed]
[13] May, L.A., Epelman, M. and Navarro, O.M. (2022) Ultrasound Imaging of Diaphragmatic Motion. Pediatric Radiology, 52, 2051-2061. [Google Scholar] [CrossRef] [PubMed]
[14] Vieira Santana, P., Zumpano Cardenas, L., Pereira de Albuquerque, A.L., Ribeiro de Carvalho, C.R. and Caruso, P. (2020) Diaphragmatic Ultrasound: A Review of Its Methodological Aspects and Clinical Uses. Jornal Brasileiro de Pneumologia, 46, e20200064. [Google Scholar] [CrossRef] [PubMed]
[15] Barbosa, F., Dos Santos, J., Alves, M., Alves, J., Cerqueira, T. and De Santana Filho, V. (2023) Inter-Examiner and Intra-Examiner Reliability of Quantitative and Qualitative Ultrasonography Assessment of Peripheral and Respiratory Muscles in Critically Ill Patients. International Journal of Environmental Research and Public Health, 20, Article 5636. [Google Scholar] [CrossRef] [PubMed]
[16] Cappellini, I., Picciafuochi, F., Bartolucci, M., Matteini, S., Virgili, G. and Adembri, C. (2020) Evaluation of Diaphragm Thickening by Diaphragm Ultrasonography: A Reproducibility and a Repeatability Study. Journal of Ultrasound, 24, 411-416. [Google Scholar] [CrossRef] [PubMed]
[17] He, Y. and Zhao, T. (2022) Ultrasound Evaluation of the Diaphragm in Clinical Anesthesia. Journal of Healthcare Engineering, 2022, Article ID: 2163225. [Google Scholar] [CrossRef] [PubMed]
[18] Schleifer, J., Shokoohi, H., Selame, L.A.J., Liteplo, A. and Kharasch, S. (2021) The Use of Angle-Independent M-Mode in the Evaluation of Diaphragmatic Excursion: Towards Improved Accuracy. Cureus, 13, e17284. [Google Scholar] [CrossRef] [PubMed]
[19] Hermans, G., Demoule, A. and Heunks, L. (2024) How I Perform Diaphragmatic Ultrasound in the Intensive Care Unit. Intensive Care Medicine, 50, 2175-2178. [Google Scholar] [CrossRef] [PubMed]
[20] Zhao, H., Liu, K., Li, L. and Zhao, H. (2024) Left Diaphragmatic Ultrasound in the Intensive Care Unit: Practical Considerations and Alternative Approaches. Intensive Care Medicine, 51, 435-437. [Google Scholar] [CrossRef] [PubMed]
[21] Boussuges, A., Finance, J., Chaumet, G. and Brégeon, F. (2021) Diaphragmatic Motion Recorded by M-Mode Ultrasonography: Limits of Normality. ERJ Open Research, 7, 00714-2020. [Google Scholar] [CrossRef] [PubMed]
[22] Zhang, L., Ni, S., Zhou, X. and Zhao, Y. (2019) Hemorrhagic Shock Sensitized the Diaphragm to Ventilator-Induced Dysfunction through the Activation of IL-6/JAK/STAT Signaling-Mediated Autophagy in Rats. Mediators of Inflammation, 2019, Article ID: 3738409. [Google Scholar] [CrossRef] [PubMed]
[23] van den Berg, M.J.W., Heunks, L. and Doorduin, J. (2024) Advances in Achieving Lung and Diaphragm-Protective Ventilation. Current Opinion in Critical Care, 31, 38-46. [Google Scholar] [CrossRef] [PubMed]
[24] Gao, L., Zhang, B., Qi, J., Zhao, X., Yan, X., Li, B., et al. (2024) Effects of Individualized Positive End-Expiratory Pressure on Intraoperative Oxygenation and Postoperative Pulmonary Complications in Patients Requiring Pneumoperitoneum with Trendelenburg Position: A Systematic Review and Meta-Analysis. International Journal of Surgery, 111, 1386-1396. [Google Scholar] [CrossRef] [PubMed]
[25] 中华医学会麻醉学分会“围术期肺保护性通气策略临床应用专家共识”工作小组. 围术期肺保护性通气策略临床应用专家共识[J]. 中华麻醉学杂志, 2020, 40(5): 513-519.
[26] Mueller, G., Aszalos, E., Krause, S., Niederhauser, T., Slavei, K. and Baumberger, M.E. (2023) Safety and Feasibility of Noninvasive Electromagnetic Stimulation of the Phrenic Nerves. Respiratory Care, 68, 602-610. [Google Scholar] [CrossRef] [PubMed]
[27] Morris, I.S., Dres, M. and Goligher, E.C. (2022) Phrenic Nerve Stimulation to Protect the Diaphragm, Lung, and Brain during Mechanical Ventilation. Intensive Care Medicine, 48, 1299-1301. [Google Scholar] [CrossRef] [PubMed]
[28] Luo, J., Wang, L., Wei, B., Huang, Z., Zheng, H., Gu, B., et al. (2025) Effects of Sedatives on Diaphragm Activity Monitored by Ultrasound: A Systematic Review and Meta-Analysis. BMC Anesthesiology, 25, Article No. 325. [Google Scholar] [CrossRef] [PubMed]
[29] Müller-Wirtz, L.M., O’Gara, B., Gama de Abreu, M., Schultz, M.J., Beitler, J.R., Jerath, A., et al. (2024) Volatile Anesthetics for Lung-and Diaphragm-Protective Sedation. Critical Care, 28, Article No. 269. [Google Scholar] [CrossRef] [PubMed]
[30] Thilen, S.R., Weigel, W.A., Todd, M.M., Dutton, R.P., Lien, C.A., Grant, S.A., et al. (2023) 2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade: A Report by the American Society of Anesthesiologists Task Force on Neuromuscular Blockade. Anesthesiology, 138, 13-41. [Google Scholar] [CrossRef] [PubMed]
[31] Wang, X., Guo, K., Sun, J., Yang, Y., Wu, Y., Tang, X., et al. (2024) Semirecumbent Positioning during Anesthesia Recovery and Postoperative Hypoxemia: A Randomized Clinical Trial. JAMA Network Open, 7, e2416797. [Google Scholar] [CrossRef] [PubMed]

为你推荐