腹腔镜右半结肠切除术外侧入路和内侧入路合理选择:争议与共识

The reasonable operative approach choice of lateral or medical approch for laparoscopic right hemicolectomy:Controversy and consensus

腹腔镜右半结肠切除术的解剖标志、手术层面等手术关键技术日益成熟,淋巴结清扫范围及消化道重建方式逐步规范,完整结肠系膜切除理念得到广泛推广。选择合适的手术入路对规范淋巴结清扫范围、寻找正确解剖平面以及减少术中并发症同样具有重要意义。腹腔镜右半结肠癌根治术的中间入路具有较高肿瘤安全性和操作便利性。外侧入路方式目前临床较少采用,适用于肠系膜上血管区域粘连严重或肠系膜炎症导致局部组织层次显露不清等情况。尾侧入路既满足结肠癌根治的全系膜切除原则,同时较中间入路操作更加简便易行。头尾侧联合入路方式是在尾侧入路的基础上进行的改良,可减少对大网膜、结肠及其系膜的多次翻动,并有助于缩短腹腔镜手术的学习曲线。关于腹腔镜右半结肠切除术不同入路法的近远期疗效的高质量研究有限,目前尚无最佳手术入路的定论。

The key technologies of laparoscopic right hemicolectomy,such as anatomic mark and operative level,are becoming more and more mature.The scope of lymph node dissection and the way of digestive tract reconstruction are gradually standardized,and the concept of complete mesocolic excision is widely promoted.It is also of great significance to select the right surgical approach for standardizing the scope of lymph node dissection,finding the right anatomical plane and reducing the complications during the operation.The middle approach of laparoscopic radical right colon cancer radical resection has high tumor safety and convenient operation.The lateral approach is currently rarely used clinically,and is suitable for situations such as severe adhesions in the vascular region above the mesentery or inflammation of the local tissue caused by mesentery inflammation.The caudal approach not only meets the principle of total mesentery resection for colon cancer radical resection,but also is more simple and easy to perform than the middle approach.The head-to-tail approach is an improvement based on the caudal approach,which can reduce multiple turnovers of the omentum colon,and mesentery,and help shorten the learning curve for laparoscopic surgery.There are limited high-quality studies on the short-and long-term effects of different approaches to laparoscopic right hemicolectomy,and there is currently no conclusive conclusion on the best surgical approach.