腹腔镜下肾切除术转手助腹腔镜与转开放手术的疗效比较

Comparison between open and hand assisted laparoscopic nephrectomy converted from difficult laparo-scopic nephrectomy

目的对困难腹腔镜下肾切除手术进行探索，并观察转手助腹腔镜与转开放手术的术中与术后临床指标，为临床应用提供参考。方法1999年12月至2006年11月行各类腹腔镜下肾切除手术273例，23例因出血、粘连、肿瘤侵犯周围脏器等原因改变手术方式。其中转手助腹腔镜手术组12例，男8例，女4例，年龄19-73岁，平均52岁，左侧7例，右侧5例；转开放手术组11例，男6例，女5例，年龄32-68岁，平均48岁，左侧5例，右侧6例。观察2组改变手术方式后的手术时间、出血量、切口长度、术后起床活动时间、肛门排气时间、住院时间等指标。结果转开放组1例死亡，其余病例均顺利完成。转手助腹腔镜组改变手术方式后手术时间为（40．1±12．5）min，术中出血量（377±311）ml，切口长度（6．2±2．7）cm，肛门排气时间（2．2±0．6）d，下床活动时间（2．2±1．1）d，术后住院时间（5．4±1．6）d；转开放手术组改变手术方式后手术时间（80．2±37．6）min，术中出血量（854士306）ml，切口长度（19．8士2．5）cm，肛门排气时间（2．5±0．5）d，下床活动时间（4．2±0．8）d，术后住院时间（10．2±2．9）d。与转开放组相比，转手助腹腔镜组在改变手术方式后手术时间、出血量、切口长度、下床活动时间、术后住院时间方面均有明显优势（P〈0.01）。结论腹腔镜下肾切除手术遇到困难时，转手助腹腔镜手术可作为一项安全合理的选择，较转开放手术出血少、创伤小，恢复快。

Objective To compare the clinical results of open and hand-assisted laparoscopic nephrectomy converted from difficult laparoscopic nephrectomy. Methods From December 1999 to November 2006, 273 patients underwent laparoscopic nephrectomy. Of them, 23 cases accepted operative style conversion for bleeding, severe adhesion or tumor infiltration. Twelve difficult cases were converted into hand-assisted laparoscopic operation （8 men and 4 women） and 11 cases were converted into open surgery （6 men and 5 women）. Clinical data including operative time, estimated blood loss, incision length, passage of gas by anus time, bed off time, postoperative hospital stay were recorded and compared. Results One patient died of bleeding in open group, and the others were performed successfully. In hand-assisted laparoscope group, operative time after conversion was （40. 1±12.5） min, estimated blood loss was （377±311）ml, incision length was （6.2±2. 7）cm, passage of flatus time was （2.2±0.6）d, out of bed time was （2.2±1.1）d, postoperative hospital stay was （5.4±1.6）d. In open group, operative time after conversion was （80.2±37.6）min, estimated blood loss was （854±306）ml, incision length was （19.8±2.5）cm, passage of flatus time was （2.5±0.5）d, resume walking time was （4.2±0.8） d, postoperative hospital stay was （10.2±2.9） d. Compared to open group, hand-assisted laparoscope group had obvious advantage in operative time after conversion,estimated blood loss, incision length, resume walking time and postoperative hospital stay（P〈0.01）.Conclusions Hand-assisted laparoscopic nephrectomy is a good choice when laparoscopic nephrectomy is difficult or in urgent situation.