腹腔镜全直肠系膜切除术手术技巧与手术副损伤的预防

Operational Skills of Laparoscopic Total Mesenteric Excision and Prevention of Its Secondary Damages

目的探讨如何合理运用手术技巧避免腹腔镜全直肠系膜切除术(laparoscopic total mesenteric excision,LTME)的手术副损伤的发生。方法对我院2005年1月～2008年6月182例LIME治疗低位直肠癌的临床资料进行回顾性分析,就手术过程中的手术入路、肠系膜下血管及降结肠系膜处理、直肠系膜游离等手术技巧进行总结,寻找避免手术副损伤发生的方法。结果182例均顺利完成LIME,无中转开腹。手术时间115～320min,平均150min。术中出血量15～75m1,平均25m1。术中直肠损伤发生率2.7%(5/182),骶前静脉丛损伤发生率2.2%(4/182),阴道损伤发生率1.1%(2/182),精囊、输精管损伤发生率1.1%(2/182),未发生输尿管损伤、前列腺损伤等。13例手术副损伤镜下缝合或压迫止血成功,术后无吻合口漏等并发症发生。术后病理:低分化腺癌56例,中分化腺癌98例,息肉恶变28例。Dukes分期:A期23例,B期67例,C期92例。182例术后随访6～32个月,平均18个月,均未发现吻合口肿瘤复发及远处转移。结论只要熟练地掌握乙状结肠、直肠毗邻结构的镜下解剖,运用合理的手术技巧和规范的操作可以防范LIME手术副损伤的发生。

Objective To explore the operational skills of laparoscopic total mesenteric excision （LTME） so that to avoid its secondary damages. Methods Clinical data of 182 patients with lower rectal cancer, who received LTME from January 2005 to June 2008, were analyzed retrospectively. The approach of the operation, ligation of the inferior mesenterie vessels, and separation of the descending colonic mesentery and rectal mesentery were investigated to determine the techniques to avoid secondary damage. Results None of the patients were converted to open surgery. The mean operation time in this series was 150 min （range： 115 to 320 min）, and the mean blood loss was 25 ml （range： 15 to 75 ml ）. The rate of secondary damages were as follows： the incidence rates of rectal lesion was 2.7% （5/182） , presacral venous plexus lesion 2.2% （4/182） , vaginal lesion 1.1% （2/182） , seminal vesicle and deferent duct lesions 1. 1% （2/182）, no ureteral or prostate lesions were found. All the secondary damages were managed successfully with laparoseopy. No complications of anastomotic leakage occurred after the operation. Conclusion Being familiar with the laparoseopic anatomy of the sigmoid colon and rectum, reasonable operational skills and standard manipulation are keys in preventing the secondary damage of LTME.