后腹腔镜根治性肾切除术肾静脉及属支损伤的处理及预防

The countermeasures and prevention about injury of the renal vein or its branches in retroperitoneal laparoscopic radical nephrectomy

目的:探讨后腹腔镜下肾癌根治术中肾静脉及属支损伤的处理对策及预防方法。方法:回顾性分析收治238例后腹腔镜下行肾癌根治术视频,总结术中肾静脉及属支损伤的原因及处理措施。手术均采用同样步骤处理肾血管,剔除腹膜外脂肪,纵行切开Gerota筋膜,以腰大肌为背侧标志游离肾脏背侧,于肾脏中部逐渐分离暴露肾动静脉,Hemo-lok及钛夹处理肾血管。结果:238例患者术中发生肾静脉及属支损伤12例,其中肾静脉损伤7例,生殖静脉2例,腰静脉2例,肾上腺中央静脉1例。9例患者术中于第3个Trocar近腋中线方向旁开2横指处增加第4个Trocar。所有患者术中发生出血后即予增加腹压(15 mm Hg),纱布压迫,尽量吸净出血,获得相对清晰视野明确出血部位后进行下一步处理。1例患者为肾静脉离断后近端钛夹脱落,出血明显,视野不清改开放手术;1例生殖静脉撕裂出血采用纱布压迫止血后,近心端用可吸收线缝扎止血;2例肾静脉近端撕裂出血采用血管缝线8字缝合止血;其余8例均采用钛夹及Hem-o-lok钳夹止血,肾脏切除后减少气腹压力,再次检查出血区域,未见明显出血。结论:肾静脉及属支损伤的主要原因是术前对肾血管分支及走向误判、术野暴露欠佳、操作粗暴等。术中冷静处理,综合采用增加Trocar、调整气腹压力、压迫、钳夹、缝合等方法多可处理。术前完善影像学检查并充分评估预判、良好暴露以及寻找解剖标志可有效预防肾静脉及其属支损伤。

Objective:To investigate the countermeasures and prevention about injury of the renal vein or its branches in retroperitoneal laparoscopic radical nephrectomy.Methods:We analyzed the video of retroperitoneal laparoscopic radical nephrectomy in our department between April 2008 and May 2012 to summarize the causes and countermeatures about injury of the renal vein or its branches in operations.Three Trocars were rountinely placed in each operation.Same steps were adopted to dissect the renal vein:removing the extraperitoneal fat,longitudinally incising Gerota fascia,dissecting the back of renal with the sign of psoas major,separating and exposing the renal artery in the middle of the renal gradually,ligating renal vessels with Hem-o-lok and titanium clip.Results:In all 238 patients,renal vein or its branches injury in operation occurred in 12 cases,including 7 cases of renal vein injury,2 cases of genital vein injury,2 cases of lumbar vein injury and 1 case of adrenal central vein injury.9 cases added a Trocar at the level of the 3rd Trocar about 2 fingers wide with the direction to midaxillary line.The methods of abdominal pressure(15mm Hg)increasing or gauze pressing were used when bleeding occurred in each patient during the operation,in order to get a clearer vision about bleeding place to do the intensive treatment.1 case conversed to open surgery because of severe bleeding caused by the titanium clip dropping off from the renal vein when it was cut,1 case of genital vein slitting used gauze pressing to prevent bleeding,1 case of proximal renal vein slitting used figureof-eight suture to make bleeding stop,other 6 cases prevented bleeding through titanium clip or Hem-o-lok using, decreased abdominal pressure after renal removed,no obvious bleeding existed.Conclusions:Injury of renal vein and its branches is relatively common in retroperitoneal laparoscopic radical nephrectomy.Misjudgment of renal vessel's branches and their directions,poor exposure of operative field and rough operating are main reasons to the injury. Most of these problems could be solved by proceeding with cool-headed and adding Trocar,adjusting abdominal pressure,pressing,clipping,suturing and so on.Completing image checking,evaluating patient's condition exactly before operation,exposing perfectly and finding anatomic signs can prevent renal vein and its branches from injuring effectively.