腹腔镜下肾脏部分切除术(附58例报告)

Laparoscopic Partial Nephrectomy:A Report of 58 Cases

目的:探讨腹腔镜下肾脏部分切除术的临床疗效。方法:肾肿瘤患者58例,包括肾癌43例,血管平滑肌脂肪瘤14例,肾素瘤1例。瘤体直径1～6cm,平均2.5±1.5cm,均采用后腹腔镜下肾肿瘤剜除术。手术过程:分离暴露肾动脉和瘤体,血管阻断夹阻断肾动脉,距离瘤体1cm用超声刀剜除完整瘤体,1-0可吸收线间断缝合创面,解除血管阻断,观察出血情况,对出血点予以缝合止血,取出肿瘤,完成手术。结果:3例因瘤体较大,或多支动脉仅夹闭1支而出血较多中转开放。手术时间65～200min,平均95±43min;术中出血20～1 500mL,平均140±60mL。血管阻断时间最初10例30～45min,后48例仅为8～28min;肠道功能12～36h恢复,绝对卧床3～5d后下床活动,术后住院7～10d。随访6～48个月。术后肾图显示患侧肾脏血流良好,功能无明显异常;1例切口种植转移,1例肾门淋巴结转移,2例因术后病理报告切缘阳性而再次开放手术行根治性切除。结论:后腹腔镜下保留肾单位的肾肿瘤切除术除具有创伤小,康复快等优点外,还可以有效保留肾脏功能,适合于处理外生性生长、直径<4cm的恶性肿瘤或者稍大良性肿瘤。手术对术者腔镜下缝合打结技巧要求较高,血管控制时间一般不超过30min,需要有一定经验的医师操作。

Objective： To investigate the clinical value of laparoscopic partial nephrotomy. Methods： Fifty-eight patients were treated with laparoscopic surgeries, of which 43 had renal tumors, 14 had hamartoma and 1 had Renin tumor. The diameter of tumors ranged 1-6 cm, （2.5±1.5cm on average）. Surgeries were performed through retroperitoneal route： exposing the tumor and renal artery; dragging the renal artery with block folder; resecting the tumor with lcm normal renal tissue by Ultracision; compressing the wound surface with homeostasis carcasses and suturing it with line; relaxing the tube;taking out the tumor tissue and finishing the surgery. Results： Three cases were turned to open surgery because of tumor of large size or multi-artery or bleeding. The surgical duration ranged from 65 to 200 min, with an average of 95±43 min. The introperative blood loss was 20 to 1500 mL approximately, with an average of 140±60mL. The artery block time was 30-45 min in the first 10 cases and 8-28 min in the other cases. Intestinal tract function recovery time and the postoperative hospital stay were 12-36 hours and 10-14 days, respectively. The patients must stay in bed for 7 to 10 days. During follow up of 6 to 48 months, patients＇ renal blood flow showed no obvious abnormal features, 1 case had incision metastasis, 1 case had renal portal lymph node metastasis, 2 cases had pathological positive margin and were treated with open radical resection. Conclusion： The laparoscopic enucleation of the renal tumors is a non-invasive, safe and effective therapy and can be considered as the first choice for patients with exophytic malignant tumors smaller than 4cm and benign tumors of larger size.