肾上腺疾病的腹腔镜手术经验

Experience of laparoscopic adrenalectomy for adrenal diseases

目的总结腹腔镜肾上腺切除术的手术经验,探讨腹腔镜微创技术在肾上腺疾病中的应用特点。方法回顾性分析2005年9月-2009年11月上海交通大学医学院附属瑞金医院泌尿外科施行腹腔镜肾上腺切除术的589例患者的临床资料。男220例,女369例,年龄16~72岁,中位年龄为45岁。肾上腺病灶直径为0.5~7.5cm,中位直径为3.2cm。病灶位于左侧329例,右侧260例。术前所有患者均行肾上腺CT形态定位检查。经后腹膜入路588例,经腹入路1例;579例采用三孔腹腔镜手术,10例因术中视野暴露不佳增加第4孔。结果6例（1.0%）术中转开放手术,其中术中未发现与术前影像学相似的肾上腺病灶3例,渗血较多视野暴露差2例,粘连严重1例。术后病理检查显示,原发性醛固酮增多症408例（单侧肾上腺腺瘤358例、单侧肾上腺皮质增生50例）,库欣综合征67例（单侧肾上腺腺瘤60例,原发性色素性结节状肾上腺病4例,促肾上腺皮质激素-非依赖性大结节状肾上腺皮质增生3例）,嗜铬细胞瘤30例,无功能腺瘤49例,肾上腺囊肿24例,髓样脂肪瘤5例,转移癌4例,肾上腺皮质癌1例,黑素瘤1例。结论腹腔镜肾上腺手术是治疗肾上腺良性疾病的金标准,但对于嗜铬细胞瘤、高危库欣综合征,手术仍存在一定风险。对大体积、恶性肿瘤,腹腔镜技术存在一定限制;对肾上腺小肿瘤,术中存在寻找困难而需转行开放手术、术中遗漏病灶等可能。术中解剖性游离并探查整个肾上腺组织是手术成功的关键。

Objective To summarize our clinical experience and to discuss the characteristics of laparoscopic surgery for adrenal diseases.Methods We retrospectively reviewed the medical records of 589 consecutive retroperitoneoscopic adrenalectomies performed during September 2005 to November 2009.The patients included 220 males and 369 females,with age ranging from 16-72 years old.The tumor size ranged 0.5-0.7 cm（with a mean of 3.2 cm,right side in 260 and left side in 329）.All patients underwent the CT scanning preoperatively.A total of 588 patients underwent retroperitoneoscopic adrenal surgery and one patient underwent the transperitoneoscopic management.Most patients received the 3-port surgery,while some of the cases received 4-port surgery to improve the surgical field.Results Conversions to open surgery were necessary in 6 patients（1.0%）.Reasons for conversions included：target discrepant with the preoperative imaging in 3,massive hemorrhage in 2,and severe adhesion in 1.The postoperative histopathological results showed primary hyperaldosteronism in 408（unilateral adenoma in 358,unilateral hyperplasia in 50）,cushing syndrome in 67（unilateral adenoma in 60,primary pigmented nodular adrenocortical disease [PPNAD] in 4,ACTH-independent macronodular adrenal hyperplasia [AIMAH] in 3）,pheochromocytoma in 30,non-funtional adrenal adenoma in 49,adrenal cyst in 24,myelolipoma in 5,adrenal metastasis in 4,adrenalcortical carcinoma in 1,and melanoma in 1.Conclusion Though laparoscopic adrenalectomy is the gold standard for management of benign adrenal lesions,surgical risks still exist for some functional adrenal diseases such as pheochromocytoma and high-risk cushing syndrome.There is still some limitations for laparascopic approach in managing large and malignant tumors.Meanwhile small adrenal tumors can be missed during operation.Anatomically isolating and exploring the whole adrenal tissue during the operation are the key points of the operations.