腹腔镜根治性膀胱切除术中盆腔淋巴结清扫的技术改进

The technical improvement and standardization of pelvic lymphadenectomy for laparoscopic radical cystectomy

目的介绍腹腔镜根治性膀胱切除术中盆腔淋巴结清扫的手术方法改进及其疗效。方法2002年12月至2007年12月我院施行了129例膀胱癌腹腔镜盆腔淋巴结清扫术。本组男性111例，女性18例。手术技巧的改良分为早期探索阶段和技术标准化阶段。早期探索阶段（25例）：尝试不同器械、不同手术次序、不同手术技巧的淋巴结清扫方法；技术标准化阶段（104例）：采用吸引器、电凝钩及血管闭合器（LigaSure）相结合的方法，按标准化的手术次序进行盆腔淋巴结清扫，其中13例施行扩大淋巴结清扫。结果全部病例盆腔淋巴结清扫术在腹腔镜下顺利完成。技术标准化阶段完成双侧标准盆腔淋巴结清扫术（91例）时间（76．1±17．8）min，出血量（62．6±30．7）ml，术中损伤髂外静脉（1．1％，1／91），术后淋巴漏发生率（2．2％，2／91），与早期探索阶段相比较，手术时间缩短、出血量减少、并发症减少。术后随诊1～5年，无继发出血，无下肢淋巴水肿，8例出现局部复发，6例发生远处转移。结论采用吸引器、电凝钩及LigaSure相结合的改良方法行腹腔镜盆腔淋巴结清扫术能减少术中并发症，缩短手术时间，减少术后淋巴漏，肿瘤控制效果满意。

Objective Laparoscopic pelvic lymphadenectomy（LPL） was one of important procedure of laparoscopic radical cystectomy, but the technical standard of LPL was still absent. We modified LPL by combined using suction, electronic hook and Ligasure. Here we report our preliminary result with this new procedure. Methods Between December 2002 and December 2007, a total of 129 patients with invasive bladder carcinoma, including 111 males and 18 females were treated with LPL. Patients＇ age ranged from 31 to 81 years old （mean 60.2）. The technical improvement was divided into two phages as early exploration phage and standardization phage. In exploration phage, 25 cases of LPL were performed by various instruments, various manipulate sequence, such as that began LPL from the obturator nerve area, combined used electronic hook and metal clip to separate-clip-cut. In standardization phage, 104 cases of LPL were done by combined using suction, electronic hook and ligaSure. The standardized sequence was to dissect ureters flint, and then remove the fatty and lymphatic tissue from the surface of bifurcation of common iliac artery to iliac vessels, dissected the lymphatic tissue around obturator nerve by LigaSure. The final step was to remove the lymphatic tissue posterior to iliac vessels. 13 patients with suspected pelvic lymphatic node metastasis by preoperative CT or MRI was performed extended LPL. Results All the pelvic lymphadeneetomy was completed by lapascopy, no conversion to open surgery. 118 orthotopic neobladder, 8 ileal conduit and 3 ureterostomy were performed for these cases consequently. Compared with that of standardization phage, the operation time of exploration phage was longer, the rate of vessel damage was higher and the rate of lymphatic leakage was higher. In standardization phage, the operation time of standard pelvic lym- phadenectomy was （76.1±17.8）min, lymphatic nodes was removed by standard pelvic lymphadenectomy. Positive lymphatic node was detected in 16 cases. Two lymphatic leakages were occurred in the group of standard pelvic lymphadenectomy perioperatively, which were cured by drainage. One to five years was follow-up, 8 local recurrences and 6 distant metastases were found. Goneltmions The modified technique of LPL by combined using suction, electronic hook and LigaSure might decrease the rate of complication during operation, cut down operation time, reduce the rate of lymphatic leakage and achieve high tumor control rate.