基于脾门血管解剖的腹腔镜胃上部癌脾门淋巴结清扫术

Laparoscopic spleen-preserving hilar lymph nodes dissection based on splenic hilar vascular anatomy

目的探讨基于不同类型脾门血管解剖的腹腔镜胃上部癌脾门淋巴结清扫术的临床应用。方法回顾性分析2010年7月至2011年3月福建医科大学附属协和医院收治的39例施行腹腔镜脾门淋巴结清扫的胃上部癌患者的临床资料和血管解剖资料，总结根据不同脾门血管类型采取的不同淋巴结清扫策略。结果本组39例患者手术成功实施，无中转开腹者，无因术中损伤脾血管或脾实质而行脾切除术者。患者脾动脉走行：Ⅰ型25例，Ⅱ型8例，Ⅲ型4例，Ⅳ型2例；脾动脉终末支分支：集中型28例，分散型11例；脾叶动脉：一支型3例，二支型24例，三支型11例，多支型1例。患者胃短血管平均数目为（3．2±1．4）支（2—6支），脾门淋巴结平均清扫时间为（30±7）min，脾门淋巴结平均清扫数目为（2．8±2．1）枚。患者术中平均出血量为（20±7）ml（0—55m1）；术后平均住院时间为（10±1）d，术后并发症发生率为10％（4／39）。全组患者获得随访，随访截至2012年3月，1例患者出现肝转移，无术后死亡患者。结论熟悉脾门部的血管解剖有利于腹腔镜胃上部癌脾门淋巴结清扫术的推广和应用。

Objective To investigate the efficacy of laparoscopic spleen-preserving hilar lymph nodes dissection based on splenic hilar vascular anatomy. Methods From July 2010 to March 2011, the clinical data of 39 patients with advanced proximal gastric cancer who underwent laparoscopic spleen-preserving hilar lymph nodes dissection at the Union Hospital of Fujian Medical University were retrospectively analyzed. Different types of vascular anatomy were analyzed, and different methods of lymph node dissection in the splenic hilus were adopted accordingly. Results The operation was successfully performed on all the patients, with no conversion to open surgery or spleneetomy due to splenic vascular or parenehyma injury. There were 4 types of splenic artery running, including type Ⅰ （25 patients）, type Ⅱ （8 patients）, type Ⅲ （4 patients） and type Ⅳ （2 patients）. There were 2 types of the end branches of splenic artery, including concentrated type （28 patients） and dispersion type （ 11 patients）. The splenic lobial vessels of all the patients were anatomically classified and divided into 4 types, including a single branch of splenic lobial vessels in 3 patients, 2 branches in 24 patients, 3 branches in ll patients and multibranehes in 1 patient. The mean number of short gastric vessels was 3.2±1.4 （ range, 2-6）. The time for dissection of the lymph nodes in the splenic hilum, number of lymph nodes dissected in the splenic hilum, volume of operative blood loss, duration of hospital stay and incidence of complications were （30±7） minutes, 2.8 ±2. 1, （20±7）ml （range, 0-55 ml）, （10± 1）days and 10% （4/39）. All patients were followed up until March, 2012. One patient had hepatic metastasis, and no patient died postoperatively. Conclusion Familiar with the variation of splenic hilar vascular anatomy is helpful in mastering and promoting laparoseopic spleen-preserving hilar lymph nodes dissection.