中间入路腹腔镜下行完整结肠系膜切除根治右半结肠癌35例可行性与技术要点分析

The technical feasibility of laparoscopic complete mesocolic excision(CME) with medial access for right-hemi colon cancer

目的探讨腹腔镜下完整结肠系膜切除(complete mesocolic excision,CME)根治右半结肠癌的技术可行性。方法回顾性分析2010年3月至2011年9月上海交通大学医学院附属瑞金医院行腹腔镜CME术35例的临床病理数据及视频资料,分析其安全性与技术可行性;采用West分级系统评价手术质量;通过解剖学绘图描述腹腔镜CME的手术入路,解剖层次及技术要点。结果 (1)脏层筋膜呈"信封样"包绕整个结肠系膜,需超声刀锐性分离脏壁层筋膜,达到血管根部结扎与完整系膜切除。(2)中间入路以回结肠血管解剖投影为起步点,沿肠系膜上静脉为主线解剖血管,进入Told与肾前筋膜间的天然外科平面。(3)盲肠及升结肠癌,需清扫回结肠、右结肠及结肠中血管根部淋巴结;结肠肝曲癌,还需清扫No.6淋巴结及切除距肿瘤以远10～15cm胃大弯侧胃网膜。(4)35例均成功完成腹腔镜下CME;手术质量等级判定C级33例;中位清扫淋巴结数19(15～25)枚,Ⅲ期病人系膜根部淋巴结阳性25%;中位手术时间2.6(2～4)h,术中出血80(50～300)mL,术后排气时间2(1～4)d,住院时间12(6～20)d;术后发生肺部感染1例,出血1例,乳糜漏1例。结论 CME为基于胚胎解剖学与肿瘤外科学的新理念,有望成为规范化手术方式;中间入路腹腔镜下CME技术上可行,是否改善远期疗效有待对照研究证实。

Objective To investigate the feasibility and technical strategies of laparoscopic complete mesocolic excision （CME） for right-hemi colon cancer. Methods The clinicopathological data of 35 cases with right-hemi colon cancer underwent laparoscopic CME between March 2010 and September 2011 in Ruijin Hospital, Shanghai Jiaotong University School of Medicine were analyzed retrospectively. The quality of surgery was assessed using the method reported by West and the surgical approaches, anatomic planes and technical tips were also elucidated by drawings and videos. Results The mesocolon was covered by the visceral fascia from both sides like envelopes, which invoted the concept of CME as a technique with sharp dissection of the visceral plane from somatic one. The ileocolic vessel was served as a dissection trigger and dissection along superior mesenteric vessel and in the embryological plane formed by Told＇ s and prerenal fascia were the two key points in medial access. Central ligation of the supplying vessels was needed to obtain an increased lymph node removal. All the 35 cases were successfully performed laparoscopic CME and the 33 specimens were evaluated pathologically as mesocolic plane. The total number of lymph nodes removed was 15--25 and central lymph node metastasis was found in 5 cases of stage HI. The median operation time was 2.6 h and the blood loss was 80 mL. The median time for passage of flatus and hospitalization were 2d and 12d respectively. Complications were observed in 3 cases. Conclusion CME is a novel concept for colon cancer and might be a standardization surgical procedure. Laparoscopic CME with medial access is technically feasible and randomized trials are needed to evaluate its long-term outcomes.