免辅助切口腹腔镜手术治疗低位直肠癌

Incisionless laparoscopic excision of low rectal carcinoma

目的探讨免辅助切口腹腔镜对低位直肠癌行根治术的可行性及近期临床疗效。方法回顾性分析2002-2005年行腹腔镜免辅助切口对低位直肠癌行根治术69例的临床资料（研究组），并与同期68例行辅助切口腹腔镜低位直肠癌术（对照组）进行对比研究。统计学分析：计量资料采用t检验，计数资料采用x。检验。结果两组均顺利行直肠癌根治性切除，保肛率100％，无中转开腹及严重并发症。对照组和研究组手术时间分别为（150±25）min和（130±22）rain（t=4．97，P〈0．05），住院费用分别为（17900±850）元和（9900±750）元（t=58．43，P〈0．05），腹部切口长度分别为（5±1．5）cm和0cm（t=27．69，P〈0．05）。对照组与研究组术中出血量分别为（75±26）ml和（77±23）ml（t=0．47，P〉0．05），清除淋巴结数量分别为（11．5±2．3）枚和（12．1±1．6）枚（t=1．77，P〉0．05），切除标本长度为（15．5±3．2）cm和（15．8±3．5）cm（t=0．52，P〉0．05），肿瘤下缘距远切端距离为（2．5±0．6）cm和（2．6±0．5）cm（t=1．06，P〉0．05）。术后胃肠功能恢复时间分别为（48±2．3）h和（48±3．1）h（t=0．00，P〉0．05），手术后镇痛剂使用率分别为88％和86％（χ2=0．05，P〉0．05）。所有患者均获随访45～79（平均59．9）个月。研究组术后9个月排便功能基本正常。两组1、3年肿瘤复发率分别为0、0和3％、1％，1、3年生存率分别为99％、97％和96％、96％，差异无统计学意义（x。=0．00、0．32、0．35、0．15，P〉0．05）。结论免辅助切口腹腔镜低位直肠癌手术符合肿瘤学根治的原则，具有可行性。与传统腹腔镜术式相比，该技术节省手术时间及住院费用。

Objective To study the feasibility and curative effect of incisionless laparoscopic total mesorectal excision of low rectal carcinoma in which an abdominoperineal resection was conducted without an accessory incision for the removal of the tumor containing bowel segment. Methods From January 2002 to January 2005, 69 low rectal carcinoma （ 〈 7 cm from the anal verge） patients undergoing incisionless laparoscopic total mesorectal excision （ study group）, in comparison with 68 patients receiving traditional laparoscopic assisted total mesorectal excision （ control group ）. The operative procedures,clinicopathological data and short-term outcomes were compared. Results All the patients accepted laparoscopic operation successfully. The operating time in control group and study group was （150 ± 25 ） min versus （ 130 ± 22 ） min （ t = 4. 97, P 〈 0. 05 ）, the hospital fee was （ 17900 ± 850 ） RMB yuan versus （9900 ±750） RMB yuan （t =58. 43, P 〈0. 05）, the length of abdomen incision was （5 ± 1.5） cm versus 0 cm （ t = 27.69, P 〈 0. 05 ）, the blood loss was （75 ± 26） ml versus （77 ± 23 ） ml （t = 0.47, P 〉 0. 05 ）, the number of lymph node dissected was （11.5±2.3） versus （12.1±1.6） （t=1.77, P〉0.05）, the resected specimen length was （15.5 ±3.2） cm versus （15.8 ±3.5） cm （t =0.52, P 〉0.05）, the negative distal margin was （ 2. 5 ± 0. 6 ） cm versus （ 2. 6 ± 0. 5 ） cm （ t = 1.06, P 〉 0. 05 ）, the time of bowel function recovery was （ 48 ± 2. 3 ） h versus （48 ± 3.1 ） h （ t = 0.00, P 〉 0. 05 ） and the use of analgetics was 88% versus 86% （χ2 =0. 05 ,P 〉 0.05 ）. All the patients were followed-up from 45 months to 79 months （average 59.9 months）. The 1-,3-year recurrent rate and survival rate were 0.3% and 99%, 96% in study group, and those in the control group were 0.1% and 97%, 96% respectively, with the difference being not significant （χ2 = 0.00, 0.32, 0.35, 0. 15, P 〉 0.05）. Patients in both group all regained satisfactory bowel continence 9 months after operation. Conclusions Incisionless laparoscopic total mesorectal excision with anal preservation is in line with oncologic principle, and a safe and feasible approach to the surgical treatment of lower rectal cancer, with the advantage of shorter operation time, shorter hospital fee and more cosmetic.