肥胖症的整形外科治疗

实施减肥手术后，肥胖症病人在获得体重大幅度降低的同时又将面临皮肤松弛、下坠等新的问题，这在胸、腹、腰、臀甚至四肢组织部分都表现得十分突出，因此许多肥胖症病人又将需要通过去脂整形手术解决这方面问题，本章我们重点介绍在胃肠减肥手术同时或后续进行的去脂整形手术治疗。

去脂整形术可分为脂肪切除术与吸脂整形术两类，前者是将过多的脂肪皮肤组织切除，后者是将多余的脂肪吸出，可根据患者的情况选择不同的手术方法，亦可将两种方法结合起来运用。随着科学的进步，人们对体型美观要求的不断提高，整形外科在去脂整形术方面也取得了理论和技术方面的进展。

一、相关概念

1.腹部的浅筋膜　腹部浅筋膜较厚，由疏松结缔组织和脂肪组织构成。在脐以下，浅筋膜分为两层，浅层为脂肪层，厚而富于脂肪，称Camper筋膜，深层称Scarpa筋膜，较致密，含弹性纤维，在中线处附着于腹白线。Illouz[273]认为局部脂肪堆积主要是深层脂肪细胞肥大的结果；而Gasperoni等[274]则认为深浅层脂肪细胞均有肥大。传统上认为吸脂手术应主要去除深层脂肪[275]。现在认为，深层脂肪在局部脂肪堆积和增加体重方面起着重要作用，而浅筋膜脂肪则在体型重塑方面起着重要作用。吸脂术要去除的是深层脂肪和浅层深部脂肪，保留浅层浅部的脂肪，这样既可以去除皮下的大部分脂肪，又可使术后皮肤保持比较柔软而有弹性。操作时将抽吸管插入浅层深部脂肪层“品”字孔向下吸取浅层深部脂肪同时通过浅层抽吸深层脂肪，一个部位抽吸完后再用手指捏皮肤检查深层是否留有脂肪，如仍有脂肪，再将吸取管插入深层吸取深层深部的残留脂肪。

2.腹壁的血供　随着腹壁成形术的发展，学者们对腹部血供进行了解剖学方面的深入研究，Huger将腹部血供分成3个区，l区由腹壁上动脉供应，2区由下腹壁深、浅动脉供应，3区由节段性的肋间血管供应。基于这种对腹壁血供解剖研究方面的认识，Alan Matarasso提出与手术联合运用时，将吸脂的程度和安全性分为4个分区，即可抽吸区、限制区、小心抽吸区、无限制区。周兴亮等[276]于1991年首次提出吸脂相对禁区的概念，即在腹、臀、股三个部位，将各主要皮支血管的穿出点及其周围区域划为相对禁区，位于腹部正中线的两侧，相当于腹直肌前鞘的纵行区域为腹部吸脂的相对禁区。

3.腹部美学标准　理想的腹部形态为扁平型，即腹部略微后收，下腹微隆，正中凹陷，腹直肌轮廓可见，脐周区亦略凹陷的形态。

4.腹部肥胖分型和治疗方案　为了更好地塑造体形，减少并发症，Bozo1a等[277]提出了以下腹部肥胖分型和治疗方法（表10-1）。

二、去脂整形术的发展

1.皮肤脂肪切除术　最早的手术方法是仅切除腹壁皮肤和脂肪，包括以下两种手术方式：

表10-1　腹部肥胖分型和治疗方案

（1）多余脂肪皮肤切除术：女性肥胖症往往表现在腹部、上臂、臀部、大腿等处的脂肪堆积过多，同时常会伴有不同程度的皮肤松垂。自20世纪初开始，国外许多医生便设计各种形式的切口来切除多余的脂肪和收紧松垂的皮肤。进入20世纪80年代，国内也有医生报道切除多余脂肪皮肤的减肥术，一直沿用至今。但因术中创伤大、出血量多及术后可能会出现切口愈合不良、皮肤部分坏死等问题，另外术后长期遗留较长和多条手术切口瘢痕影响美观的问题，需要慎重选择适应证。

手术操作：沿设计切口切开皮肤达皮下脂肪层，一般在深筋膜上方，向两侧潜行分离，注意血管神经走形方向，避免误伤，必要时用电刀水平切开脂肪，有明显出血点时电凝或结扎，掀起较多脂肪的一侧皮肤形成皮瓣，保留皮下0.5～1.0cm脂肪层后切除多余脂肪，防止误伤真皮下血管网，向对侧牵拉皮瓣，切除多余皮肤部分后，对拢缝合皮下脂肪层、真皮下层，使皮肤在无过大张力下严密间断缝合。

术后注意事项：皮瓣下留置负压引流管1～3d，术区外敷棉垫弹力绷带或腹带确实地加压包扎，不宜太紧（易造成压迫血液循环或远端水肿），也不易太松（易造成淤血或皮下血肿），手术部位制动1周。

（2）腹部脂肪皮肤切除及腹壁肌筋膜紧缩术：中老年肥胖者，腹部脂肪堆积、皮肤松垂同时常伴有一定程度的腹壁腹直肌和筋膜松弛使腹腔内容物易突出。所以在腹部脐下或脐略上以下做垂直形切口，若原有剖宫产刀瘢痕者更适宜此方法。在切开皮肤、切除两侧过多皮下脂肪和松弛皮肤的同时，将腹直肌前鞘暴露，在前鞘筋膜垂直切开，两侧略作游离后作纵向的横行褥式折叠缝合，腹壁肌肉轻度松弛者可仅作部分腹直肌前鞘“8”字位拢缝合，以此可收紧腹壁肌肉层，达到更有效的收腹作用，也可更有效缓解皮瓣缝合后的皮肤张力。术后除进行有效的弹力腹带加压包扎外，还需在两周内避免咳嗽和用力解大便，以防止腹直肌前鞘缝合线崩开。

（3）腹壁整形术：源于1890年法国的Demars和Mars进行的腹壁整形术，其最早的方法是仅切除腹壁皮肤和脂肪，随着整形外科医生对手术方法的不断改进，逐渐形成了现代的腹壁整形术，主要包括以下步骤[278]：①皮肤切除，去除多余的脂肪和皮肤；②折襞术（plicate），将松弛的腹直肌前鞘折叠；③脐移位，将脐移到新的位置。这些方法有着明显的缺点如：较长的手术瘢痕，皮肤感觉减退等。目前这种传统的腹壁整形术的应用已受到限制[279]。仅适用于皮肤重度松垂的患者，其主要并发症有切口较大，遗留手术瘢痕、皮肤坏死、血肿、血清肿等。

20世纪80年代后期，皮肤脂肪切除术方面又有了新的发展：①迷你（mini）的概念：国外学者Wilkinson、Swartz和Greminger提出了迷你腹部成形术的概念，它与传统腹部成形术的区别主要在于重点放在纠正下腹部的缺陷，适用于下腹部有多余的脂肪和皮肤，伴有脐下腹直肌的松弛，即可采用此法，此术式的优点是创伤小，较短而隐蔽的切口，以“W”形，“U-M”形常用。切口位置一般在腹股沟上延伸到骸前上嵴内2cm左右。②内镜：女性往往是腹膜外脂肪堆积，腹直肌松弛常与怀孕、肥胖和年龄相关；三四十岁的男性腹直肌松弛而皮肤却不松弛，对于这种类型的腹部缺陷，是行内镜下腹部整形的主要指征。③并发症的预防：术后血清肿，常见于腹部下方，表现为局部胀满感，站立时局部膨隆明显，或可触及液体震荡感。为使其发生率降至最低，术后患者均应放置引流管，并在引流量<15ml后拔除。渐进性张力缝合，不放置引流管，也可减少局部并发症。

2.吸脂整形术　吸脂整形术到目前为止，共经历了单纯机械性抽吸技术、肿胀技术、体内超声技术和体外超声技术四个发展时期。

（1）单纯机械性负压吸脂术：最早可追溯到20世纪70年代初Schrud de用刮宫器借助负压进行脂肪刮吸术，此后意大利的两兄弟Arped和Geoge Fisoher进行了脂肪抽吸术，这些单纯负压吸脂手术机械性损伤大，术后出血、血肿及血清肿的发生率高，皮肤坏死的情况也时有发生。

（2）肿胀技术下的负压吸脂术：现代吸脂的转折点是1987年Klein[280]和Toledo[281]提出了在肿胀技术下行闭式吸脂术，即在抽吸区注入少量肾上腺素，大量低浓度的利多卡因，15～30min后再进行脂肪抽吸，以使吸脂出血量和并发症降至最低。肿胀技术由于低渗液的局部注射，压迫血管使之闭合，吸脂术后渗血、出血的并发症明显减少，同时使该手术可以在门诊局麻条件下操作，是较为安全的方法，但是存在费时费力的缺点。

1987年，Reployle[282]发明了皮下超量灌注湿性吸脂术，使吸脂术进入了“低创去脂”时代。超量灌注钝性吸脂是由肿胀技术衍生而来，根据患者情况、吸脂部位，在肿胀麻醉的基础上联合应用硬膜外麻醉或全身麻醉。但应注意把握“超量”的含义，即使用的利多卡因总量可超过我国药典规定的安全范围，最大可达35mg/kg，肿胀灌注液内利多卡因浓度＜0.1g/L，肿胀吸脂术安全、有效而彻底[283-285]。但这是以低浓度配合使用肾上腺素及碳酸氢钠为前提的。生理盐水中加入碳酸氢钠（每1 000ml灌注液加5～10ml），以减少注射时的刺激及疼痛，并且减少细胞外存留的离子化的利多卡因[286]，如果用乳酸林格液则不需用碳酸氢钠。目前，对最大抽吸量达多少为安全尚未确定，但只要不盲目增加抽吸部位，控制利多卡因用量，注意观察失血量，在一定范围内适当增加抽吸量仍属可行。此外，还应注意体液平衡，以免发生水中毒和电解质紊乱。三通连续注射器、弹簧加压泵等器械的运用缩短了肿胀液灌注的时间[287]。注液量与抽吸量比例一般在1.51∶～21∶，这将使失血量降至最低，占吸出总量的1%～5%[288]。

1992年Fischer设计出了站立位吸脂手术台，并对站立位吸脂技术作了报道，对吸脂手术台亦更新了三代。1996年，Botti描述了站立位检查和手术的步骤。1999年Shuter[289]提出站立位吸脂才是真正的体型雕塑。此后国内也有人尝试坐位、屈膝半卧位吸脂，以提高吸脂效果。同时运用细管吸脂使全身各处的抽吸成为可能，面颊、头颈、手臂、腿部等部位的抽吸都起到了令人惊奇的效果。身体周缘的抽吸，如肋两侧、臀部等部位的抽吸更使腰围缩小，体形更加令人满意。

（3）超声辅助负压吸脂术：1992年，意大利的Zocchi[290]，首先报告了超声辅助吸脂术，使吸脂术进入了“微创去脂”的时代。超声波是一种每分钟振动2万次以上的机械振动波，其在液体介质中传导可产生以下作用[291,292]。

①微机械作用：通过机械振动作用，使液体充分扩散。

②热作用：超声波传导过程中在通过不同的组织界面能量逐渐衰减，当肿胀液被灌注于脂肪层后，脂肪层对超声波能量的吸收增加，使超声波达到更深组织的能量衰减，部分转化为热能。

③空泡效应：超声波在液体内的传导过程中，由于超声的声压差可在瞬间“牵拉”水分子，产生“空泡”，然后瞬间再消失。足够强度的超声波能使脂肪细胞内产生微腔，随着超声波的持续作用，微腔内的气体不断膨胀，气泡呈现一种机械共振，同时伴有小范围液体流动，一方面产生剪切力破坏亚细胞结构，另一方面细胞间的肿胀液发生振荡使脂肪细胞连接疏松组织黏附力减弱。

超声通过以上三种作用使注入到皮下的肿胀液均匀地扩散到皮下脂肪组织中，使脂肪组织肿胀疏松，组织间隙（脂肪与脂肪、脂肪与血管神经组织间隙）增宽。脂肪组织变得疏松后，吸脂时小块脂肪组织易于吸出。组织间隙增宽则可减少血管、神经纤维的损伤，减少出血。超声使得肿胀液均匀地扩散到脂肪组织中，充分达到了肿胀脂肪组织的目的。

由于体内超声技术中超声头需置于皮下，热效应不易控制，相对容易形成热损伤的副作用，并且乳化作用较慢，操作时间过长，因此临床应用受到了限制。1998年体外吸脂开始应用于临床。体外超声使用的超声频率比体内超声高1万倍以上，使能量在肿胀组织中顺利传导，作用至离皮下数厘米范围内，故超声作用更快更有效，皮温升高不明显，因此发生皮肤烧伤、皮下脂肪液化等并发症的概率大大减少[293]；同时，体外超声与体内超声[294]相比，吸出的脂肪量较大，效果更为明显。而且体外超声具有其独特的皮肤收缩作用，使术后皮肤弹性回缩快，皮肤术后的皱折不明显。目前广泛认为体外超声吸脂安全、有效、损伤小。体外超声可以最快速度使脂肪乳化，又术后并发症出现最少，体内超声次之、单纯法则最多[294-297]。

总之，超声吸脂技术与传统吸脂术相比有更多优点[295]：①选择性破坏脂肪细胞，而细胞周围的血管、神经、淋巴管可以完整的保留；②仅去除脂肪细胞的液体成分，而高密度的固体成分留在原位，吸后皮肤十分平坦；③超声波特有的皮肤收缩效应，特别适用于皮肤较松弛的患者；④由于其选择性作用，从而避免了传统吸脂造成的出血、休克、脂肪栓塞，增加了手术安全性；⑤对于医师来说省时、省力，对于患者来说创伤小、出血少、恢复快、皮肤平坦，患者易于接受。

（4）吸脂术与切脂术的结合：对于各种不同类型的腹壁缺陷可选择不同的治疗方法，对于Ⅱ、Ⅲ、Ⅳ、Ⅴ型缺陷的患者均可使用吸脂术与切脂术两种方法相结合，进一步提高治疗效果，即所谓的“marriage”法[298,299]。

三、吸脂整形术的相关问题

1.吸脂整形术的适应证和禁忌证

（1）适应证：如果仅从整形外科体型重塑的角度来看，吸脂术并不能治疗肥胖症，因此手术的对象一般是健康者，普遍认为是体重超出标准体重<30%。但如果我们从外科肥胖症综合治疗的角度去考虑问题时，吸脂整形术或去脂整形术完全可以用作胃肠外科肥胖症治疗的辅助治疗或后续治疗的重要组成部分。因此我们不必将体重超出标准体重30%的肥胖症患者排除在外。

（2）禁忌证：重大疾病（如慢性阻塞性肺疾病、缺血性心脏病、高血压控制不良等），严重的全身性疾病等。对于体重超过标准体重30%、轻度糖尿病及皮肤松垂者，手术应慎用。此外，患者应有一种合理的期望值，并通过改变生活方式，包括饮食习惯和锻炼来巩固减肥手术及塑形手术的治疗效果。

美国整形外科医师协会为吸脂术制定了以下安全原则：①适应证选择恰当：健康、超重＜30%标准体重；②使用肿胀技术；③密切监测出入量（尿量、血压、心电监护），与麻醉师交流补液情况；④维持体液平衡：吸出量＜5L时，仅需输入维持液体量；吸出量＞5L时，每超过1ml补充0.25ml晶体液；⑤吸出量＞5L时需留院观察过夜；⑥全麻患者需使用正压通气装置或术后持续延长全麻1h；⑦利多卡因剂量＜35mg/kg[301,302]。

2.吸脂整形术的并发症　吸脂手术的并发症由于缺乏统一的标准，故文献报道差异较大，从不到0.1%到9.3%[300,303,304]，死亡率为0.002 6%～0.02%[301,304,305]，美国整形外科医师协会于1998年统计了全美24 295个吸脂者并发症发生率为0.66%[301]，其中较常见的并发症为0.37%，重大并发症的发生0.29%，其中死亡5例（0.02%），手术风险的增加与液体过量、超量脂肪吸出及手术操作不当、本身健康不良有关。Teimourian[304]调查了美国皮肤科医师协会自2001年8月～2002年10月共66 570例吸脂手术，严重并发症为0.68%，经分析，门诊手术与住院手术相比并不增加并发症的发生率。单纯肿胀法吸脂较联合静脉麻醉或肌内注射麻醉发生并发症的概率低。国内对吸脂术的并发症报道极少，几乎未见有严重并发症的报道，而且国内对吸脂术也缺乏严格的管理，难以作出客观的统计。应注意以下若干并发症。

（1）感染：感染在吸脂术中并不多见，严格的手术器械消毒非常重要，Meyers等[306]曾报道了由于手术器械消毒不彻底，污染手术，致6个月内的82例吸脂者中的34例（41%）出现皮肤胀肿，经培养证实为分枝杆菌。在常规吸脂术时，一般只需口服广谱抗生素3～5d，在大量吸脂或合并其他开放性手术时应在术中术后预防性应用头孢类抗生素。感染发生时，须根据细菌培养及药敏试验结果选择抗生素，大部分致病菌为金黄色葡萄球菌。坏死性筋膜炎是外科急症，致病菌为多种厌氧菌或溶血性链球菌，典型症状是体检时发现术区的异常疼痛，必须在症状发现后的24～36h内及时治疗，可行外科扩大清创，应用大剂量抗生素及高压氧治疗[307]。

（2）血肿及血清肿：应用肿胀技术，一般损伤大血管的可能性较小。曾有报道1例腰部吸脂术后出现低血容量性休克，经血管造影证实双侧腰动脉损伤，行栓塞治疗[303]。血清肿是最常见的并发症，大部分发生在腹部，尤其是大量吸脂时，以超声吸脂多见。术中控制超声的使用时间及强度，应用较细的抽吸管以及术后不要过早解除弹力加压包扎，以避免血清肿的发生。治疗采用多次抽吸或放置引流管，局部应用海绵垫弹力加压[303,307]。

（3）皮肤坏死：原因主要为抽吸平面过于浅表，皮下血管过度受损。应用超声时，要注意超声的热灼伤和对血管的损伤。热损伤仅发生于超声吸脂，应注意两个原则：①必须在皮下灌注后的湿润环境下使用超声；②超声探头不能固定于一个部位[307]。

（4）脂肪栓塞综合征：大量脂肪栓塞于肺血管的最小分支，从而增加肺的灌注压，导致右心衰竭，在单纯吸脂术中并不多见，大部分发生在合并腹壁整形术及其他开放性手术时[307]。

（5）液体失衡：吸脂术最初采用的干性法由于创伤大，失血量大，已很少使用。Illouz采用的湿性法是指在治疗部位先注射配制的低渗液体（1 000ml生理盐水＋200ml蒸馏水＋10 000U透明质酸酶＋60mg利多卡因），如为局麻，可加入1mg肾上腺素，在全麻下因应用氟烷，禁用肾上腺素。Illouz称之为水剥离法，水剥离使出血减少，更好地掌握组织层次，一般注入量与吸出量为11∶。Illouz认为采用湿性法吸脂，避免一次抽吸过量脂肪，皮下灌注液适量，不易发生液体失衡[308,309]。20世纪80年代，Klein[310,311]的肿胀技术吸脂法和Fodor[301,312]等的超灌注法相继在临床应用，在皮下注入含利多卡因和肾上腺素的等渗液体，使抽吸部位水肿坚硬，然后进行抽吸，不需全麻、硬膜外或者静脉麻醉。肿胀法的皮下灌注量与吸出物的比例为31∶甚至更高，超灌注法为（1～2）1∶，皮下注射的大量等渗液体，防止了大量的血管内外液体交换，同时稀释的肾上腺素溶液大量浸润，弥散到整个手术部位，产生完全的血管收缩，使出血量很少，一般失血量为吸出总量的1%[313]。手术方法及技术的改进，使一次手术吸出大量皮下脂肪成为可能。肿胀法及超灌注法吸脂对吸出量的限制尚无报道，一般认为吸出量>4～5L[311,303,307,313]时为大量脂肪抽吸，应视为中等或较大手术，伴有较大程度的体液变动和心血管方面的诸多问题。Klein[310]认为肿胀法吸脂时，大量灌注液会进入血管内，不需要静脉补液，但维持静脉通道还是必要的。研究表明大约70%的灌注液存留体内，除了手术后渗出外，大量的液体经血管吸收[301,313-315]。术中补液根据以下几方面来决定：①补充术前缺水量，根据禁食时间长短而定；②维持液量：吸脂为中等创伤手术，输液为每小时5～6ml/kg，可根据术中监测血压、心率、呼吸及尿量调整；③术中丢失：Trott认为应用超灌注技术时，在吸出总量超过4L时需补液，每超过1ml补充1ml晶体液[313]，而在美国整形外科医师协会，认为应用肿胀技术，抽吸量＞5L时才需补充晶体液，每超过1ml补充0.25ml[301]。

（6）利多卡因及肾上腺素中毒：大量吸脂术中（吸出物＞5L时）伴有大量利多卡因的应用。利多卡因做皮下浸润麻醉时，总量＜400mg（7mg/kg体重），这并不适用于肿胀麻醉，Klein连续测定血浆浓度，发现吸脂时可降低利多卡因全身吸收的10%～30%，即相同比例的利多卡因通过吸脂排出体外，血清中利多卡因的峰值出现于皮下灌注后的12h，应用剂量为35mg/kg时，患者血清中利多卡因浓度低于中毒剂量5μg/ml。肿胀麻醉效果持续18h[310,311]。Ostad[316]报道术中仅有1%～10%的利多卡因被吸出，使用利多卡因的安全剂量为76.7mg/kg。一般认为，吸脂手术利多卡因的应用总量应限制在35mg/kg内[301]。中毒早期表现包括：头晕、倦怠、谵妄、口苦、口舌无味，这时血浆浓度为3～6μg/ml；达5～9μg/ml时，出现颤抖，肌肉颤动；当＞10μg/ml时，出现抽搐，中枢神经系统抑制及昏迷，最终导致呼吸抑制和心跳骤停。早期发现症状后，可采取保持气道通畅增大肺通气量，加强心肺支持，应用地西泮提高中枢的耐受性[305]。

（7）肾上腺素和碳酸氢钠：肾上腺素是肿胀液配方中的主要成分之一，它可使注射部位血管收缩，手术失血量大为减少，还可减缓利多卡因吸收，延长效应，避免中毒反应。这种延缓吸收的作用使更多的利多卡因通过吸脂同时被吸出[305]。Burk[317]认为在利多卡因安全剂量的前提下，肾上腺素的安全剂量为10mg。但Matarasso[286]建议肾上腺素使用剂量为0.07mg/kg，一般浓度为11∶ 000 000到18∶ 000 000均有效。肾上腺素的血清峰值大约在注射后3h，可达生理值的4倍，到12h后恢复正常。在嗜铬细胞瘤、甲状腺功能亢进症、严重高血压、心脏病或周围血管疾病患者，肾上腺素要慎用。据统计大约10%女性有二尖瓣脱垂，对肾上腺素很敏感。肾上腺素使用剂量为0.07mg/kg，以4mg为限。中毒时会出现高血压及心律失常。

（8）深静脉血栓形成及肺栓塞：深静脉血栓形成的症状包括疼痛、小腿背侧紧压感，很少能触摸到条索状物。可通过Doppler超声检查等确诊。肺栓塞的症状、体征包括：胸痛、呼吸困难、咯血、精神状态不稳定、心动过速、呼吸急促、发热、肺啰音，可做胸片、通气-灌注扫描来确诊。危险因素有：高龄（＞40岁），口服避孕药，肥胖，长时间麻醉及同时施行开放性外科手术。预防的方法有早期活动及抬高下肢（超过心脏），应用肺的正压通气装置及低剂量皮下肝素应用（对于高危者尤其是肥胖者）。治疗应尽早使用抗凝药物，包括静脉使用肝素[307]。

（9）腹壁穿孔：文献中至少曾有过9例该类报道，其中4例死亡。危险因素有：腹壁疝（包括脐疝），以前曾有多次腹壁手术史（导致腹壁粘连），以前曾行吸脂术，由于瘢痕及皮下层的不规则亦可增加危险。术前要详细了解腹部手术史，检查腹部瘢痕及腹壁疝的存在，必要时作CT扫描及超声检查[307]。

四、腹部去脂的麻醉方法

目前，常采用的麻醉方法有膨胀剂（含麻药）局部浸润麻醉、静脉全身麻醉、硬膜外麻醉。

局部浸润麻醉就是在手术部位的皮下脂肪内注入3 000～4 000ml的肿胀液，肿胀液内含利多卡因400mg、肾上腺素1mg、5%碳酸氢钠30～40ml，然后进行手术吸脂。但此时患者情绪过于紧张、烦躁、血压升高，影响手术顺利进行，甚至有患者要求停止手术。而现代的麻醉要求患者绝对安静、对人体的各器官影响最小，以有利于术后患者的康复。

静脉全麻是一种比较舒适的麻醉方法，但氯胺酮可引起梦幻和呕吐，虽然辅用丙泊酚后，氯胺酮的副作用已经大幅度下降，但梦幻和呕吐还是有一定的发生率。

硬膜外阻滞只要操作成功，辅以神经安定镇静剂可以完成下肢、下腹部、中上腹部手术，可施行控制性降压，是减少术中大出血的有效方法。它不仅使与手术区相关的交感神经充分阻滞，而且也使手术部位的向心传导阻滞，从而降低了交感神经紧张性，去甲肾上腺素分泌得以稳定。降低了患者的应激反应，术中生命体征平稳，镇痛完全，完全能满足手术和患者的要求[318]。

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