后腹腔镜解剖性肾上腺切除术

Technique of anatomical retroperitoneoscopic adrenalectomy

目的介绍后腹腔镜解剖性肾上腺切除术的手术方法及临床效果。方法2000年2月至2005年10月，对800例患者采取后腹腔镜解剖性肾上腺切除术。常规制备后腹腔操作空间。切开Gerota筋膜后，按顺序分别进入3个相对无血管解剖层面进行分离。第一分离层面位于肾脏内上方脂肪囊与前层Gerota筋膜之间，此层面可以在手术初期快速找到肾上腺；第二分离层面位于肾外上方脂肪囊与后层Gerota筋膜之间；第三分离层面位于肾上腺下方与肾上极之间。最后处理肾上腺中央静脉。依术前诊断和术中情况选择行肾上腺全切或次全切术。结果除1例嗜铬细胞瘤（肿瘤直径7．8cm）患者因肾上腺肿瘤与肝脏及下腔静脉粘连紧密行中转开放手术外，全部手术均成功完成。平均手术时间（45±19）min，平均术中出血量（25±11）ml。恢复饮食和下床活动时间分别为1.2d和1．0d。12例（1．5％）出现术后皮下气肿、皮下血肿或切口感染。除6例特发性肾上腺增生患者术后1年高血压复发外，其余患者临床症状均消失或明显好转。结论后腹腔镜解剖性肾上腺切除术解剖层次清楚，术野清晰，疗效确切，为肾上腺外科疾病的治疗提供了更加安全的选择。

Objective To introduce the technique and clinical effect of anatomical retroperitoneoscopic adrenalectomy （ARA）. Methods From February 2000 to October 2005, ARA was performed in 800 consecutive patients with surgical adrenal lesions. Under general anaesthesia, retroperitoneal space was created routinely at lateral decubitus position. After incising the Gerota＇s fascia, three relatively bloodless planes were orderly entered for exposure and separation of the adrenal gland. When entering the first dissection plane between the perirenal fat and anterior Gerota＇s fascia located at the superomedial side of kidney, the adrenal gland could be identified at the initial stage of the operation. The following dissections proceeded in the plane between posterior Gerota＇s fascia and lateral aspect of perirenal fat, and in the avascular plane located on the parenchymal surface of upper renal pole. The adrenal vein was dealt with at the final stage. Total or subtotal adrenalectomy was selected with regard to comprehensive consideration of the preoperative diagnosis and intraoperative actual condition. Operative time was defined as the time from skin incision to skin closure. Results All operations succeeded except one case with large pheochromocytoma converted to open surgery. The mean operative time and estimated blood loss were （45 ± 19） min （range, 25 to 230） and （25 ± 11） ml （range, 5 to 200）, respectively. Average days to oral intake and ambulation were 1. 2 and 1. 0, respectively. Major complications and perioperative mortality were not experienced. Minor post-operarive complications occurred in 12 patients （1. 5%）. The procedures resulted in marked clinical improvements in the patients with horrnone-secreting tumor, except 6 patients with idiopathic adrenal hyperplasia. Conclusions ARA is a safe and effective ment of surgical adrenal diseases.