经肛内镜全直肠系膜切除治疗直肠癌

NOTES transanal endoscopic total mesorectal excision for rectal cancer

目的首次报道并介绍经肛内镜对1例合并左侧游走肾的男性直肠癌患者实施全直肠系膜切除(TME)的NOTES手术方法。方法新辅助化疗后施行NOTES手术,手术分两组:腹组经腹腹腔镜辅助分离直肠上端和乙状结肠及其系膜以及肠系膜下血管,肛组游离直肠系膜,术者在PPH肛门镜下横断直肠壁后先完成腹组以上操作,再进行肛组操作,通过自制的腰形直肠镜按照TME原则向上分离直肠系膜直至从骶前间隙进入腹腔,盆底腹膜前部的分离经前腹壁腹腔镜下进行,经肛门直肠镜将直肠和乙状结肠拖出,切断乙状结肠并用吻合器将直肠和乙状结肠吻合。结果手术时间290 min,直肠系膜完整切除并检出25个淋巴结,其中5个直肠下部系膜淋巴结阳性,直肠及其系膜的远切缘阴性,最后病理分期pT3N2,术后患者恢复顺利,第2天开始肠内营养,第5天和第8天分别开始半流质饮食和普通饮食,未发生吻合口漏和感染,第7天后排便功能接近正常。结论自然腔道手术经肛内镜全直肠系膜切除可行而安全,腹腔镜辅助有利于克服精囊腺和游走肾造成的分离困难。

【Objective】To report a male patient with rectal cancer and left ectopic pelvic kidney who under-went transanal endoscopic total mesorectal excision（TME） as one of the styles of natural orifice transluminal endo-scopic surgery（NOTES）,and to recommend the procedures of NOTES applied in the case.【Methods】NOTES was performed after neoadjuvant chemotherapy.The performed NOTES was divided into two parts： in transabdominal part,laparoscopic dissection of the rectosigmoid and the inferior mesenteric vessels was performed;mesorectum dis-sociation was performed in transanal part.The transabdominal and transanal operation was successfully finished by the operater after the transection of rectum through PPH anoscope.The bottom-up transanal mesorectum dissection was performed through a self-made waist-shape proctoscope and was terminated when entering abdominal cavity from presacral space.As a result of being hindered by the seminal vesicle,mesorectum dissection in the forepart of pelvic floor peritoneum was transabdominally laparoscopically performed.Once the enough length of sigmoid colon was confirmed,the rectosigmoid was transanally exteriorized through proctoscope,and the specimen was eventually transected followed by stapled colorectal anastomosis.【Results】The operative duration was 290 minutes.25 lymph nodes were retrieved from the specimen of mesorectum which was completed,5 nodes of the lower mesorectum were pathologically positive.The final pathology demonstrated pT3N2 with negative margins of distal rectum and mesorec-