后腹腔镜下根治性肾切除术完整标本取出切口的随机对照研究

Intact specimen extraction during retroperitoneoscopic radical nephrectomy： a randomized controlled study

目的探讨后腹腔镜下根治性肾切除术完整取出标本的适宜切口。方法因肾癌需实施后腹腔镜下根治性肾切除术的连续性住院病例119例，按随机数字表随机分为2组，腹部切口组60例，腰部切口组59例。手术均由同一组医生实施，完整标本取出均由同一位医生完成。统计分析2组手术时间、标本取出时间、切口长度、标本质量、术后下床活动时间、术后胃肠功能恢复时间、术后住院日、术后止痛剂用量、并发症发生率等方面的差异。结果2组患者性别、年龄、体质指数、肾脏最大横径、肿瘤分期等比较差异均无统计学意义（P〉0．05）。2组手术时间分别为（99±14）、（115±12）min（P=0．000），切口长度分别为（4．9±0．3）、（5．3±0．4）cm（P=0．000），标本取出时间分别为（14±2）、（24±6）min（P=0．000），术后止痛剂用量分别为（35±27）、（52±29）mg（P=0．002），下床活动时间分别为（20±2）、（21±4）h（P=0．016），组间比较差异均有统计学意义；2组胃肠功能恢复时间分别为（21±3）、（20±4）h（P=0．457），术后住院日分别为（6±1）、（6±1）d（P=0．476），标本质量分别为（469±181）、（459±169）g（P=0．776），组间比较差异均无统计学意义。119例切口均甲级愈合，无切口液化、感染病例。89例获随访，随访时间6～18个月，中位时间12个月，未见切口疝、肿瘤切口种植病例。结论后腹腔镜下根治性肾切除术完整取出标本时，腹部切口具有切口小、损伤少、手术时间短、术后恢复快、疼痛轻等优点，是完整取出标本较为合适的路径。

Objective To investigate the appropriate incision for intact specimen extraction during retroperitoneoscopic radical nephrectomy. Methods One hundred and nineteen patients in need of retroperitoneoscopic radical nephrectomy were randomized into two groups. One group of 60 patients received intact specimen extraction through a muscle-splitting abdominal incision. The second group of 59 patients received intact specimen extraction through a muscle-cutting lumbar incision. All procedures were performed by the same team of surgeons, and the intact specimens were extracted by the same surgeon. Standard operative features were measured and recorded （operative time, the time of specimen extraction, incision length, specimen weight, the time to get out of bed, the recovery time of gastrointestinal function, postoperative hospital stay, analgesia requirement, and complication rate）. Results The two groups were matched in regard to patient age, body mass index, the maximum diameter of the kidney, and the stage of TNM （each P 〉0.05）. There were significant differences between the abdominal incision group and lumbar incision group in terms of operative time （99 ± 14 rain vs 115 ± 12 min; P = 0. 000） , incision length （4.9 ± 0.3 cm vs 5.3 ± 0.4 cm; P = 0. 000） , the time of specimen extraction （14 ± 2 min vs 24 ± 6 min; P=0. 000） , analgesia requirement （35 ±27 mg vs 52 ±29 mg; P =0.002）, the time to get out of bed （20 ±2 h vs 21 ±4 h; P = 0. 016）. The differences were not significant between the 2 groups in terms of the recovery time of gastrointestinal function （21 ± 5 h vs 20± 4 h; P = 0. 457 ）, hospital stay （6 ±1 d vs 6 ± 1 d; P = 0. 476）, and specimen weight （469 ± 181 g vs 459 ± 169 g; P = 0. 776）. There was no complication of incision in the 2 groups at 12 months＇ follow-up （rang, 6 to 18 months）. Conclusion A muscle-splitting abdominal incision for intact specimen extraction is more appropriate than a lumbar incision during retroperitoneoscopic radical nephrectomy, with small incision, little injury, short operative time, quick recovery, and less pain.