中高位直肠癌和乙状结肠癌腹腔镜经直肠标本取出手术的保护措施

Protective measures in laparoscopic resection for upper or mid rectal cancer and sigmoid colon cancer with transrectal specimen extraction surgery

目的介绍一种自制标本保护套在腹腔镜中高位直肠癌和乙状结肠癌经直肠标本取出手术时的使用以及置入方式的改进，以避免和减少腹腔内细菌污染和肿瘤细胞散落。方法2015年6月至2017年5月期间．作者及其手术团队采用自制标本保护套对来自同济大学附属上海东方医院胃肠肛肠外科48例高位直肠和乙状结肠癌患者进行了腹腔镜直肠癌经自然腔道标本取出手术（NOSES手术）。手术适应证的选择：（1）肿瘤下缘距齿状线6cm以上的直肠和乙状结肠癌；（2）术中判断肠管连同系膜和瘤体的最大直径〈7cm：（3）既往无肛管、肿瘤远侧直肠手术和外伤等导致的直肠肛管狭窄或缺乏扩张能力等；（4）肿瘤远侧肠管没有溃疡性结肠炎、克罗恩病或放射性直肠炎等。经自然腔道标本取出手术的具体方法：离断直肠后，经由右下腹12mm的主操作孔置入标本保护套（采用中国3L公司生产的腹腔镜保护套剪裁而成，根据远侧直肠保留的长度，截取保护套一端长25—35cm制作而成．一端结扎，一端为开放的带有结扎带的开口．准备过程中袋内约5ml石蜡油冲洗润滑），腹腔内直肠残端上方保留长7～8cm；剪除经肛拖出保护套的结扎部分，经保护套内置入吻合器抵钉座，并经标本保护套将切除标本顺行经由直肠腔内向体外牵拉拖出。结果全组患者男性30例，女性18例，年龄（64．5±14．1）岁，体质指数（25．4±3．9）kg／m^2；肿瘤直径（3．3±1．1）cm，标本最大直径（5．4±1．5）cm，标本长度（18．6±4．3）cm。48例患者中，有36例（75．0％）没有明显阻力而顺利将标本拖出；有12例（25．0％）阻力较大。其中7例需要会阴组医生分次横行钳夹拖出肠管；有4例在拖出过程中，由于肠腔内气体和液体聚集肠管内而形成较大体积，故在拖出肠管壁做1em切口，向近端肠管内插人吸引器外套管，将气体和液体引出使肠管变细后拖出；还有1例因标本体积过大（肿瘤及系膜直径7．5cm）无法拖出，改为传统腹部小切口标本取出和肠道重建。6例标本发生撕裂或横断，但由于有塑料套保护，未发生污染。全组患者手术时间（113．2±76．1）min，术中出血（38．5±17.3）ml，术后初次进食流质时间（47．9±4．4）h，术后住院时间（8．5±1．7）d。术后1例（2.1％）出现吻合口瘘；无腹腔内和穿刺腔感染，无肠梗阻病例。结论标本保护套的使用以及置入腹腔方法的改进可以有效防止标本取出过程中的腹腔污染。即使体积较大的标本也可顺利取出。

Objective To introduce the use of a self-made specimen protective sleeve in laparoscopie resection for upper or mid rectal cancer and sigmoid colon cancer with transrectal specimen extraction surgery and the improvement of implantation method, so as to avoid and reduce bacterial contamination and tumor cell dissemination in abdominal cavity. Methods During June 2015 and May 2017, 48 cases of high located rectal or sigmoid colon cancer were operated laparoscopically with natural orifices specimen extraction surgery （NOSES） using a self-made specimen protecting sleeve.Operation indication ： （1） Rectum and sigmoid colon cancer with the distance of more than 6 cm from tumor inferior margin to dentate line. （2） The maximum diameter of intestine together with mesangial and tumor 〈 7 cm by intraoperative judgment. （3） No anal and distal rectal surgery, no anorectal stenosis or lack of expansion capacity caused by trauma. （4） No ulcerative colitis, Crohn＇s disease or radiation proctitis. After transecting the rectum, the specimen protective sleeve was inserted through the right lower 12 mm main Trocar （This sleeve was tailored from the laparoscopic protective sleeve produced by China 3L Corporation, which was intercepted with 25-35 cm from one end of the sleeve according to the length of distal rectal retention. One end was ligated and the other was open with a ligature band. About 5 ml paraffin oil was used to rinse and lubricate during the operation）. The rectal stump retained 7-8 cm in abdominal cavity. The transanal ligation part of the protective sleeve was cut off, then the stapler nail seat was inserted and specimen was pull out through the sleeve and rectum. Results There were 30 males and 18 females. The average age was （64.5 ± 14.1） years, the BMI was （25.4 ± 3.9） kg/m^2, the tumor diameter was （3.3 ± 1.1） cm, the maximum diameter of specimen was （5.4 ± 1.5） cm and the length of specimen was （18.6 ± 4.3） cm. Among these 48 cases, specimens of 36 patients were pulled out through inside of the sleeve easily, while specimens of 12 patients were quite difficult with resistance. Of 12 cases, 7 needed the help of transverse forceps, 4 needed to make 1 cm incision in pull-through bowel and insert a suction to decrease the volume of large specimens with gathering of gas and fluid, and 1 received small abdominal incision to remove specimen and perform intestinal reconstruction due to big specimen （the diameter of tumor and mesentery was 7.5 cm）. Specimen tears of 6 patients didn＇t result in dissemination thanks to the specimen protecting sleeve. The operation time was （113.2 ± 76.1） min, the bleeding amount was （38.5 ± 17.3） ml, the time to first oral intake was （47.9 ± 4.4） h, and the postoperative hospitalization length was （8.5 ± 1.7） d. Anastomotic leakage occurred in 1 case （2.1%）. No intra-abdominal and trocar infection, and obstruction were found. Conclusion The use of protective sleeve and the improvement of the method of intraperitoneal implantation can effectively reduce the abdominal contamination during the specimen extraction. It can be applied to big specimens as well.