直肠癌的腹腔镜微创手术体会

Experience of laparoscopic minimal invasive operation for rectal carcinoma:a report of 61 cases

目的:总结腹腔镜微创技术治疗直肠癌的手术体会。方法:2003年1月至2006年12月,61例直肠癌病人接受腹腔镜下根治手术。其中男39例,女22例,中位年龄68岁。直肠肿瘤下缘距肛缘平均(7．3±3．5)cm(3～15 cm)。结果:61例中行腹腔镜辅助手术57例(93．4％),腹腔镜手助手术2例(3．3％),中转开腹手术2例(3．3％);前切除术(AR)19例(31．1％)．低位前切除术(LAR)23例(37．7％),腹会阴联合切除术(APR)17例(27．9％),Hartmann术2例(3．3％)。全组手术中均未行结肠系膜裂孔或盆底腹膜关闭。平均手术时间为(165．2±41．7)min,其中前20例为(183．3±40．9)min,后41例为(162．7±36．2)min,两者之间存在显著差异(P＜0．05);平均手术时间随手术例数的增加而明显减少。术后发生切口感染6例(9．8％),吻合口漏1例(1．6％),吻合口出血2例(3．3％),不完全性肠梗阻2例(3．3％)。随访时间在6个月以上的有40例,平均随访时间为25(6～48)个月。随访中发生切口疝1例(2．5％),局部复发1例(2．5％),远处转移1例(2．5％),无戳创口和切口的肿瘤种植以及肠梗阻发生。结论:腹腔镜微创直肠癌根治手术存在优势;做创手术的学习曲线反映手术技术属渐进式掌握和熟练过程,也是手术团队的技术水平的反映;直肠手术中形成的系膜裂孔和盆底腹膜均无缝合关闭的必要;腹腔镜微创技术根治直肠癌,将成为结肠直肠外科的主流性手术。

Objective To analyse and summarize the experience gained in laparoscopic minimal invasive operation for rectal carcinoma. Methods Sixty-one patients （39 males and 22 females） with rectal carcinoma were submitted to laparoscopic minimal invasive radical resection during the period from Jan. 2003 to Dec. 2006. The median age of the patients was 68（44±83） years old. The average distance from the lower margin of the tumor to the anal margin was （7.3± 3.5） cm （3±15 cm）. Results Of the 61 cases, 59 （96.7%） underwent laparoscopic operation, of which, 57 （93.4%） were laparoscopy-assisted, and 2 （3.3%） were hand-assisted; 2 cases were converted to open surgery. Anterior resection （AR） was performed in 19 cases （31.1%）, lower anterior resection （LAR） in 23 cases （37.7%）, and abdominal perineal resection （APR） in 17 cases （27.9%）; only 2 cases （3.3%） were submitted to Hartmann＇s operation. Neither the mesocolon nor the pelvic peritoneum was closed in each case. The average operative time in these 61 cases was （165.2±41.70min; in the first 20 cases, the operative time was （183.3±40.9）min, while in the other 41 cases, it was （162.7±36.2）min, （P〈0.05）. The complications of the laparascopic operation were incisional infection （6 cases, 9.8%）, anastomotic leakage （1 case, 1.6%）, anastomotic bleeding （2 cases, 3.3%）, intestinal obstruction （2 cases, 3.3%）. In 40 patients who had a follow-up of 6-48 months （average 25 months）, incisional hernia occurred in 1 case （2.5%）, local recurrence in 1 case （2.5%）, distant metastasis （death） in 1 case （2.5%）. There was no tumor planting in the trocar ports or the incision. None had post- operative bowel obstruction. Conclusions Laparoscopic minimal invasive surgery does possess a lot of advantages. The learning curve reflects not only the perfect skill and craft manship of the main operator, but also the good cooperation of the team during the operation. There is no need to re-peritonize the mesocolon and the pelvic peritoneum in laparoscopic surgery. Laparoscopic minimal invasive operation will probably become the main technique adopted in colorectal surgery.