腹腔镜远端胃癌D_2根治术手术路径的临床应用研究

Surgical Approach of Laparoscopic D_2 Radical Gastrectomy for Distal Gastric Cancer

目的探讨腹腔镜远端胃癌D2根治术手术路径的临床效果。方法 2007年10月-2010年5月,对56例远端胃癌实施腹腔镜远端胃癌D2根治手术。手术路径：大网膜切除和横结肠系膜前叶剥离;解剖腹腔动脉、肝总动脉、脾动脉及清扫相应淋巴结;处理胃右动脉和5组淋巴结;清扫12a组淋巴结等顺序进行,淋巴清扫以4d→4sb→14v→6→7/9→11p→8a→5→12a→1→3的路径进行。结果手术时间130-375 min,（203.4±48.4）min。清扫淋巴结13-21枚,（16.2±1.2）枚。术后胃肠功能恢复时间48-120 h,（80.6±17.7）h。标本远近切缘无癌残留。无围手术期死亡病例。术后72 h吻合口出血1例,96 h输出端梗阻1例。56例术后随访2-31个月,（14.1±6.9）月,死亡8例：肿瘤广泛转移6例,心脑血管疾病2例;带瘤生存5例,无瘤生存43例,无瘤生存时间最长已31个月。结论腹腔镜远端胃癌D2根治术按照合理的路径进行手术,能够保证手术在正确的间隙和解剖层面进行,有利于在遵循肿瘤根治的原则下完成手术。

Objective To investigate the clinical effects of the surgical pathway of laparoscopic D2 radical gastrectomy for distal gastric cancer.Methods Totally 56 patients underwent laparoscopic D2 radical resection for distal gastric cancer from October 2007 to May 2010.The operation included 5 main steps in a certain order： first,resecting the omentum and divesting anterior lobe of the transverse mesocolon;second,anatomizing the celiac,common hepatic,splenic arteries and dissecting corresponding lymph nodes;third,managing the right gastric artery and five lymph node groups;fourth,dissecting the lymph node of 12a group;finally,the lymph nodes were dissected following the order of 4d→4sb→14v→6→7/9→11p→8a→5→12a→1→3.Results The operation time was 130-375 minutes[mean,（203.4±48.4） minutes],number of harvested lymph nodes was 13-21（mean,16.2±1.2）,and the gastrointestinal function recovery time after the operation was 48-120 hours[mean,（80.6±17.7） hours].No patient died in perioperative period.No residual tumor was detected at the distal and proximal resection margins.One patient showed anastomotic bleeding in 72 hours after the operation,and one patient developed obstruction of the output terminal in 96 hours after operation.Follow-up was achieved in all of the patients for 2-31 months[mean,（14.1±6.9） months];during which 8 patients died of extensive tumor metastasis（6 cases） or cardio-cerebrovascular disease（2 cases）.Five patients were living with tumor,34 patients were living without tumor,and the longest survival time without tumor was 31 months.Conclusions For distal gastric cancer,laparoscopic D2 radical gastrectomy with appropriate surgical pathway leads to a right space and anatomic level,which is helpful for us to follow tumor radical principle.