U形解剖在后腹腔镜肾上腺及腺瘤切除术中的应用

Application of U-shaped anatomic step in retroperitoneal laparoscopic adrenalectomy

目的总结后腹腔镜肾上腺及腺瘤切除术的经验和改进方法。方法2003年5月2010年5月，采用后腹腔镜技术行肾上腺及腺瘤切除术447例。男性175例，女性Z72例，平均年龄（39士12．8）岁（15～84岁）。原发性醛固酮增多症128例，柯兴氏综合征112例，嗜铬细胞瘤57例，副神经节瘤10例，髓脂瘤28例，肾上腺囊肿17例，神经鞘瘤11例，肾上腺髓质增生9例，原发性肾上腺结节状增生5例，原发性肾上腺癌3例，转移性肾上腺癌3例，其他单纯无功能皮质腺瘤64例；瘤体平均直径（2．8士2．1）cm（O．5-10cm）。所有病例均采用后腹腔途径，沿肾背侧缘向上游离出肾上极并尽量扩大腹膜后腔，然后在肾上极内上份的Gerota筋膜前层与腹膜反折之间的无血管间隙进行分离，其次再分离肾周脂肪囊和Gerota筋膜后层之间的无血管间隙；将前两个解剖层面在肾上极表面无血管层面连通起来，形成一个“U”形的解剖步骤，最后再离断其上份的附着部分，切下肿瘤或肾上腺，计算其手术成功率、手术时间、术中估计出血量、术后住院时间、手术相关并发症等临床资料。结秉本组手术成功率为97．3％（435／447）。因术中和术后出血、气胸、过度肥胖等而转开放手术12例。单侧手术平均时间（45土22）min（15～140min），术中估计平均出血量（35士15）mL（15∽200mL），14例需要术中、术后输血1～2单位，输血率为3．1％（14／447），术后平均住院时间（5．3士2．5）d（3～10d）。术后伤口延迟愈合、皮下气肿、发热等手术相关并发症发生率为5．6％（25／447）。砖论后腹腔镜手术对腹腔脏器干扰小，依据U形的解剖步骤，解剖层次清楚，可有效地缩短手术时间并减少出血等手术并发症。后腹腔镜手术是治疗肾上腺外科良性疾病的金标准。

Objective To summarize the experience and improve the clinical technique of retroperitoneal laparoscopic adrenalectomy. Methods From May 2003 to May 2010, retroperitoneal laparoscopic adrenalectomy procedures were performed on 447 patients with adrenal lesions （175 male and 272 female, aged 15∽84 years old）, including 128 cases of primary aldosteronism, 112 Cushing＇s syndrome, 57 pheochromocytoma, 10 paraganglioma, 28 myelolipoma, 17 adrenal gland cyst, 11 myoschwannoma, 9 adrenal medullary hyperplasia, 5 primary adrenal nodulus hyperplasia, 3 primarily adrenal carcinoma, 3 metastatic adenocarcinoma, and 64 nonfunctional adenoma. The average diameter of the adenoma was （2. 8± 2.1） cm （ranging 0. 5∽10 cm）. All patients adopted retroperitoneal approach and all the operations applied the U-shaped anatomic step to cut off the adrenal lesions. The operation time, estimated average bleeding loss （EBL）, postoperative hospitalization and complications were recorded for analysis. ReSUltS 12 cases switched to open surgery owing to bleeding, pneumothorax or greater body mass index, thus the success rate of operation was 97.3% （435/447）. The mean operative time, EBL and postoperative hospitalization was （45＋22） min （ranging 15~140 rain）, （35＋15） mL （ranging 15∽200 mL）, and （5.3 ±2.5） d （ranging 3∽ 10 d） respectively. 14 patients needed 1∽2 u of blood transfusion. The occurrence of minor postoperative complications was 5.6% （25/447）. Conclusions Retroperitoneal laparoscopic surgery has less interference on abdominal organs. The U-shaped anatomic step allows direct and clear vision of the anatomical structures, resulting in shorter operation time and lower rate of perioperational complications. Retroperitoneal laparoscopic adrenalectomy is the gold standard for treating benign adrenal diseases.