后腹腔镜根治性肾癌切除术的解剖标志

Anatomic landmarks during retroperitoneoscopic radical nephrectomy

目的探讨经后腹腔途径行肾癌根治术的解剖标志. 方法 2002年11月～2004年7月,后腹腔镜下行肾癌根治术46例.第1个trocar位置在第12肋下缘2 cm骶棘肌外侧交界处,第2个trocar位置在髂嵴上缘中点,或髂前上嵴内上方2 cm左右,第3个trocar在腋前线与肋弓下2 cm交界处.首先寻找腰大肌为背侧标志,膈肌为肾上极后侧标志,肾上腺为肾上方内侧标志,腹膜为腹侧标志.肾静脉位于肾动脉前下方.分离右肾静脉应常规分至下腔静脉汇合处.直线切割器分别切除肾动、静脉. 结果手术时间平均145 min(60～255 min),术中出血量平均133 ml(20～1 000 ml).肾上腺切除32例,占69.6%(32/46).1例由于解剖标志不清出血改为开放手术;1例直线切割器切右肾静脉时,误将腔静脉切割封闭了1/2;腹膜损伤4例.46例随访1～20个月,平均9个月.1例因肾癌肝转移,术后1年死亡,余45例无瘤生存. 结论良好的解剖标志是后腹腔镜下肾癌根治术成功的关键.

Objective To discuss anatomic landmarks during retroperitoneoscopic radical nephrectomy. Methods A total of 46 patients underwent retroperitoneoscopic radical nephrectomies from November 2002 to July 2004.The first trocar was introduced at the union of the site 2 cm below the 12 th costal margin with the lateral side of the musculus sacrospinalis.The second trocar was placed at the midpoint of the upper border of the iliac crest,or at the location above and medial to the anterior superior iliac spine.And the third one was inserted at the union of the anterior axillary line with the costal margin.In the first place,the greater psoas muscle was identified as the dorsal marker.Then the diaphragmatic muscle was identified as the posterior marker of the upper pole of the kidney,and the adrenal gland as the medial marker of the upper pole of the kidney,and the peritoneum as the ventral marker.The renal vein lay below and anterior to the renal artery.The right renal vein was routinely sperated right up to the joining site with the inferior vena cava.A linear cutter was used to resect the renal vein and artery respectively. Results The mean operation time was 145 min (range, 60~ 255 min) and the mean intraoperative blood loss was 133 ml (range, 20~1 000 ml). Adrenalectomy was performed in 32 patients (69 6%). A conversion to open surgery was required in 1 patient because anatomic landmarks could not be well seen. The inferior vena cava was wrongly closed off by 1/2 cross-section when using a linear cutter to sever the right renal vein in 1 patient. Peritoneal injuries happened in 4 patients.Follow-up was carried out for 1~20 months (mean,9 months) in all the 46 patients.One patient died of liver metastasis 1 year after the surgery, while the remaining 45 patients survived without recurrence. Conclusions Proper identification of anatomic landmarks is crucial to a successful retroperitoneoscopic nephrectomy.