全胸腔镜袖式支气管成形术

Experience of completely video-assisted thoracoscopic sleeve lobectomy

目的探讨全胸腔镜下袖式支气管成形术治疗非小细胞肺癌的安全性、有效性、手术适应证和操作注意事项。方法2011年9月至12月，完成全胸腔镜袖式支气管成形术8例，其中男7例，女1例；中位年龄62．4岁。中位肿瘤最大径2．3cm。右肺上叶袖式支气管成形术5例，左肺下叶袖式支气管成形术2例，左肺上叶袖式支气管成形术1例。手术方式为全胸腔镜下解剖性袖式肺叶切除支气管成形术＋系统性淋巴结清扫（包括至少3组纵隔区域淋巴结）。采用双腔气管插管全身麻醉，侧卧位，肩下垫枕。胸腔镜观察口放置在右侧腋中线第7肋间，长1.5cm；操作口选择在腋前线第4肋间，长4cm；辅助操作口选择在肩胛下角线第7肋间，长1．5cm。支气管吻合均为端端吻合，采用膜部单纯连续缝合＋软骨部单纯间断缝合的吻合方式，即先以4—0不可吸收缝线单纯连续缝合支气管后壁及膜部，再以3-0可吸收缝线单纯间断缝合支气管前壁，完成全周吻合。以周围带血供组织缝合覆盖支气管吻合口。常规放置胸腔闭式引流管。结果全组手术顺利，无死亡及严重并发症发生。中位手术240min，支气管吻合45min；术中出血200ml，淋巴结清扫19．8枚／例。无中转开胸病例。术后病理示鳞状细胞癌7例，腺癌1例。术后病理分期T1aN0M0 1例，T1bN0M0 4例，T1bN1M0 2例，T1bN2M0 1例。术后轻微并发症1例，为一过性窦性心动过速，经药物治疗后好转。全组患者术后恢复顺利，术后中位放置胸腔引流管时间7天，住院9天。随访3～8个月，未见肿瘤复发。结论全胸腔镜下袖式支气管成形术治疗非小细胞肺癌是一种安全、有效的手术方式；第4肋间腋前线切口进行吻合操作方便、快捷，可以避免缝线间彼此缠绕；膜部连续缝合、结合软骨部单纯间断缝合是快速、安全的缝合方式；保留奇静脉并不影响吻合操作。

Objective Summarize 8 cases of non-small cell lung cancer （NSCLC） that has accepted completely video-as- sisted thoracoscopic sleeve lobectomy in People＇s Hospital of Peking University in china, to explore the safety, effectiveness indi- cations and experience of this procedure. Methods Between September 2011 and December 2011, Medical records of 8 cases of non-small cell lung cancer that has accepted complete thoracoscopic sleeve lobectomy were reviewed （7 male, 1 female）. Median patient age was 62. 4 years. And median maximal diameter of solid tumors was 2. 3 cm. This group consisted of 5 cases of right upper lobe sleeve lobectomy , 2 case of left lower lobe sleeve lobectomy and 1 case of left upper lobe sleeve lobectomy. The opera- tion procedure was completely VATS anatomic sleeve lobectomy combined with systematic lymph node resection （ at least 3 groups of lymph nodes in the mediastinum area）. All procedure were underwent under general anesthesia with double-lumen endotracheal intubation. The patient was placed lateral deeubitus position. Three incision were made at the seventh intercostal space on the median axillary line, the fourth intercostal space anterior axillary line and the seventh intercostal space subscapularis line. Bron- chial were anastomosed combine with simple continuous suture anastomosis of membranous part of bronchus and simple interrupted suture anastomosis of cartilaginous part of bronchus, and then covered by？ Surrounding tissue with blood supply？ Results All procedures were carried out smoothly without serious complication. The median operative time was 2dOmin median, the median bronchial anastomosis time was 45 min, the median blood loss was 200 ml, and median number of resected lymph nodes was 19. 8. There were no conversion to open thoracotomy. Post operative show pathology squamous cell carcinoma in 7 cases and ade- nocarcinoma in 1 case. pTNM staging show 1 case of TlaNoM0,4 cases of TlbNoM0,2 case of TlbN1M0 and 1 case of TlbN2M0. There was 1 case of slight post operative complication. The median postoperative chest tube drainage duration was 7 days, and median postoperative hospital stay was 9 days. All patients were well during the followed up for 3 - 8 months. Conclusion Com- pletely thoraeoscopic sleeve lobectomy was a safe and effective surgical procedure for patients with non-small cell lung cancer; the operative incision placed at the fourth intercostal space anterior on the axillary line was convenient for anastomosis; anastomosis combine with simple continuous suture anastomosis of membranous part of bronchus and simple interrupted suture anastomosis of cartilaginous part of bronchus was a fast and secure mode; keeping azygos vein does not affect the anastomosis.