多入路行腹腔镜肠系膜上血管根部清扫的临床运用

2015-07-18 01:13朱剑飞朱平等
中国医药科学 2015年6期
关键词:腹腔镜

朱剑飞?朱平等

[摘要] 目的 探讨在腹腔镜辅助右半结肠全系膜切除术中多入路清扫肠系膜上血管根部的临床价值。 方法 回顾性析2011年1月~2013年12月间在腹腔镜辅助右半结肠全系膜切除术的28例患者资料,其中接受多入路清扫肠系膜上血管根部的12例,设为观察组;单纯逆肠系膜上静脉清扫的16例,设为对照组。比较两组间出血量、手术时间及清扫淋巴结数量等指标。 结果 所有患者顺利完成手术,无中转开腹。两组间多项指标比较,观察组平均大致出血量少于对照组,平均清扫淋巴结个数多于对照组;而平均手术时间、平均术后排气时间及术后下床时间两组间差异无统计学意义。 结论 采用多入路法行腹腔镜下肠系膜上血管根部清扫可降低配合要求,减少出血,清扫更彻底,更加符合无瘤手术原则。

[关键词] 全系膜切除术;腹腔镜;手术入路;肠系膜上血管

[中图分类号] R735.35 [文献标识码] B [文章编号] 2095-0616(2015)06-147-03

The clinic application of the procedure to clear the root of the superior mesenteric vessels with multi-approach

ZHU Jianfei ZHU Ping SHI Jun ZHU Qiuwei

Department of Gastrointestinal Surgery,the Second People's Hospital of Changzhou City,Changzhou 213003,China

[Abstract] Objective To investigate the clinic merit of the procedure to clear the root of the superior mesenteric vessels with multi-approach. Methods The materials of 28 patients who underwent the laparoscopic right hemicolectomy which embraced the clearing the root of superior mesenteric vessel by CME rule from January 2011 to December 2013 were retrospectively analyzed.All patients were divided into two groups.12 patients were in observation group who underwent the clear the root of SMV by the multi-approach. 16 patients were allocated to the control group who underwent the same operation by the classic approach.The information between both groups were compared,such as blood loss,operation time,harvested lymph and other indexes. Results All operations were performed successfully.NO one was converted to open operation.The mean blood loss in observation group was less than that in the control group;the average number of lymphs harvested in observation group was more than that in the control group.There were no differences of the mean operation time,postoperative anus exhaust time and under the bed time between the two groups. Conclusion The procedure to clear the root of superior mesenteric vessels with multi-approach in laparoscopic right hemicolectomy decreased the cooperative difficulty,made the blood loss less.This procedure was more in line with the no-tumor principle.

[Key words] Complete mesocolic excision;Laparoscopy;Approach;Superior mesenteric artery

德国人Hohenberger在2009年提出为克服结肠癌淋巴结跳跃转移的特点,提高术后生存率,行结肠癌根治术应遵循全结肠系膜切除(complete mesocolic excision,CME)的概念[1-2]。因大部分右半结肠淋巴结回充至腹系膜上淋巴结,经腹腔干周围腹腔淋巴结汇合成肠干注入乳糜池[3-4],有必要清扫肠系膜上静脉(superior mesenteric vein,SMV)及肠系膜上动脉(superior mesenteric artery,SMA)根部组织。但该区小静脉多,变异大,抗牵拉能力差,常导致术中出血,影响手术视野。甚至中转开腹。我科从2011年开始尝试多入路行腹腔镜下清扫肠系膜上血管根部,取得良好效果,现报道如下。endprint

1 资料与方法

1.1 一般资料

2011年1月~2013年12月间接受联合入路行腹腔镜辅助右半结肠全系膜切除术的患者28例,所有患者术前已经肠镜病理检查及腹部CT明确诊断,所有病例术前影像学证实无周围脏器累及,美国麻醉医师协会(ASA)评分[5]≤3。观察组男8例,女4例,年龄(47.2±8.7)岁。术后Dukes分期:B期2例,C1期6例,C2期4例。术后病理示:低分化腺癌4例、中分化腺癌3例、高分化腺癌1例、黏液腺癌4例。对照组男11例,女5例,年龄(52.6±7.9)岁。术后Dukes分期:B期1例,C1期8例,C2期7例。术后病理示:低分化腺癌8例、

1.2 手术方法

患者呈头高足低位,倾斜30°,“大”字型固定,术前准备、操作站位及穿刺孔位置无明显改变,同常规腹腔镜D3根治术[6-7]。手术步骤:(1)右半结肠主要血管离断。同样采用中间入路法,术者站于患者两腿之间,助手将横结肠及右结肠向上向右展开,暴露右半结肠系膜,术者持超声刀以回结肠静脉为解剖标志,沿上方解剖包裹肠系膜上静脉的血管鞘,于根部分别切断回结肠静脉、右结肠静脉,中结肠静脉右支,并于SMV左侧离断相应动脉。(2)SMV根部清扫。沿SMV上方切开横结肠系膜,继续切开SMV根部血管鞘。观察组术者改站于患者右侧,掀开胰颈部被膜,剥离胰十二指肠前筋膜,同时辨明胃网膜右静脉及SMV根部,助手站于患者两腿之间,持钳抓胃远端后壁上翻。在SMV根部血管鞘内,切断右侧汇入的胃结肠静脉干(gastrocolic trunk of henles,GTH),沿SMV根部下方切断汇入的钩突小静脉及胰十二指肠前下静脉,清除此区域内疏松组织,并切断Henle干之右结肠分支。对照组参加手术人员站位不变,手术步骤同上。(3)观察组病例术者换到左侧,在SMV左后方解剖出肠系膜上动脉,同样离断左侧及后方汇入之小血管清扫左侧相应疏松组织。对照组参加手术人员站位不变,手术步骤同上。(4)结肠系膜完整游离,切断肠管,移除右侧大网膜。切开右结肠系膜后叶,暴露Toldt筋膜与Gerota筋膜潜在间隙移除系膜,注意保护右侧输尿管。在胃网膜血管外侧,切除右侧大网膜。(5)肠管吻合,腹腔冲洗。上腹正中做一长约4cm纵行切口,在预切除线行肠管闭合式切除,并肠管吻合,关闭系膜孔,关腹后再次冲洗探查后结束手术。

1.3 统计学方法

所有数据处理采用SPSS17.0软件包进行统计学分析,计数资料采用()表示,两组均数的比较采用独立样本t检验,P<0.05为差异有统计学意义。

2 结果

两组比较,平均手术时间、术后排气时间和术后下床活动时间差异无统计学意义(P>0.05);而平均大致出血量及平均清扫淋巴结个数差异有统计学意义(P<0.05)。所有病例无中转开腹,标本切缘阴性。

3 讨论

在肠系膜上血管根部区域主要分布有胃网膜右静脉、胰十二指肠前上、前下静脉、右结肠静脉等组成的GTH[8-9],但其组成及走行变异较多,最终在右侧汇入SMV根部。另有大量的钩突小静脉、交通静脉及胰十二指肠下静脉多经下方汇入SMV。同样的,有众多微小动脉于左侧汇入SMA[10-11]。而在原手术方式中,术者多站于患者两腿之间,视线近乎平行于肠系膜血管,虽可以切断侧方注入血管,但当超刀头卷曲,极易引发沿小血管长轴的牵拉效应,因众多小静脉管壁薄,抗拉力差,极易出血。而因视野阻挡,十二指肠水平段及SMV根部间仅有极短的潜在间隙,不适合操作,致难以彻底清扫后方注入小血管。

本研究尝试从左右二侧分别行SMV及SMA清扫,观察组平均大致出血量显著少于对照组。分析原因:(1)使视角与其成近90°垂直,使这一区域易于清晰暴露;(2)操作空间扩大,可以较方便地原位切断侧方与下方血管并清除疏松组织;(3)因牵拉方向改为垂直于长轴,在一定程度改善了小血管的抗牵拉作用。(4)正因为以上优点,也减少了术中出血,使清扫更彻底,更加符合全系膜切除术淋巴结清扫的原则。

本研究也显示观察组与对照组间平均手术时间、术后排气时间及术后下床活动时间并无统计学意义,观察组多手术入路结合的方式并没有增加手术时间,未增加手术创伤,延缓患者预后。值得注意的是,在SMV根部右侧处理其属支时,因管壁薄,不必过分解剖周围组织,只要弄清血管走行及性质即可,且静脉骨骼化难于动脉骨骼化,尽可能不做过多牵拉。而在处理SMA时,先打开动脉鞘,分离清楚胰十二指肠下动脉和第1空肠动脉后再离断处理,以免误伤[12-13]。

从本研究结果可知,多入路行腹腔镜下肠系膜上血管根部清扫是可行的。且能取得更好的手术效果,同时不再需要助手在小的操作范围配合,减少了牵拉,降低了配合要求及手术难度,值得在临床进一步推广。

[参考文献]

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(收稿日期:2015-01-06)endprint

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