腹腔镜肾上腺解剖学与手术入路研究

Anatomy and approach of retroperitoneal laparoscopic adrenalectomy

目的:借助腹腔镜进行肾上腺解剖学研究并建立合理的手术入路。方法:1999年10月至2009年3月我院共行腹膜后腹腔镜肾上腺手术45例;左侧27例,右侧18例。术前拍摄CT和/或MRI,术中摄取录相,术中、术后反复观察肾上腺的解剖部位、层面、周围筋膜、与肾筋膜腔关系等,并设计合理的手术入路。结果:肾前融合筋膜、腰肌筋膜、侧锥筋膜围成肾周间隙。肾周间隙又可再分为肾上腺间隙和肾筋膜间隙两部分。肾筋膜间隙由肾筋膜前后叶环形包绕而成,容纳肾脏、肾周脂肪和肾盂输尿管鞘。肾上腺间隙的前侧边是肾前融合筋膜,外侧边是肾筋膜,内侧边是膈肌脚。肾上腺间隙内包含肾上腺和肾上腺周围脂肪。结论:肾上腺位于肾筋膜腔外,术中沿肾脂肪囊外平面可迅速到达肾上腺。

Objective：Retroperitoneal laparoscopic adrenalectomy has been selected as routine approach in many centers.The aim of this study was to reveal the actual anatomic position of adrenal gland and design a proper approach for retroperitoneal laparoscopic adrenalectomy.Methods：Forty-five consecutive retroperitoneal laparoscopic adrenalectomy were performed by one urologist from Oct.1999 to Mar.2009.There were 27 at left side and 18 at right side.CT and/or MRI scan were performed before operations.Operations were recorded. The anatomy relation of adrenal gland and fascia encountered during operation were analyzed, recorded and reconstructed. The ideal approach based on our finding was proposed. Results：Perirenal sapce is margined with prerenal fusion fascia anteriorly, lateral cone fascia laterally and transversalis fascia of psoas posteriorly. The perirenal space is divided into two parts named adrenal space and renal thseia space. Renal fascia space is enclosed by anterior and posterior lamella of renal fascia, containing kidney, perirenal fat, renal pelvis and upper ureter. Viewed transversely,adrenal space is in triangular shape, margined with prerenal fascia anteriorly,crus of diaphragma medially,and lamella of renal fascia laterally. Adrenal gland actually locates outside renal fascia space and may be seen throught transparent renal fascia. There is a vessel-less plane called experirenal tat plane locates between renal fascia and perirenal fat. Adrenal gland may be easily reached hy dissecting through this plane （experirenal fat approach）. Conclusions：Adrenal gland locates in adrenal space which is outside of renal fascia space. Adrenal gland may be easily reached by the technique of experirenal fat approach, namely, dissecting and pushing away the perirenal fat and kidney,viewing adrenal gland through transparent renal fascia.