经腹膜后入路腹腔镜活体供肾切取术中肾动脉结扎方式的临床经验分析

A clinical analysis of techniques of renal artery control in laparoscopic donor nephrectomy

目的对经腹膜后入路腹腔镜活体供肾切取术（LDN）中肾动脉的结扎方式进行分析总结。方法2003年6月至2012年6月共实施亲属活体肾移植术211例，其中2007年以后136例供肾切取均采用经腹膜后入路的腹腔镜活体供肾切取手术。在LDN肾动脉结扎中，采取开放Hem-olock夹结扎40例，腹腔镜下Hem-o-lock夹结扎87例，腹腔镜下ENIX）-GIA结扎5例，腹腔镜下Hem-o-lock夹结扎联合手辅助丝线缝扎4例。结果开放行Hem-o-lock夹结扎方式供肾热缺血时间最短，为（1．1±0．3）min，腹腔镜下Hem-o-lock夹结扎方式供肾热缺血时间最长，为（3．2±0．8）min，开放组与其他各组相比，供。肾热缺血时间的差异均有统计学意义（P％0．05）。在移植肾预后各因素的比较中，各组无明显差异。腹腔镜下单纯Hem-o-lock夹结扎中出现Hem-o-lock夹致肾动脉破裂1例，经紧急转为开放手术，持续输血和自体回输并积极维持生命体征等应急措施，供者最终手术成功，顺利出院。其余结扎方式均安全可靠，未出现不良反应。结论LDN中，开放行Hem-o-lock夹结扎方式的供肾热缺血时间最短，而腹腔镜下Endo-GIA结扎方式和Hem-o-lock夹联合手辅助丝线缝扎方式最为安全可靠；针对供肾可疑有严重动脉粥样硬化等高危人群的LDN，Hem-o-lock夹对肾动脉的结扎需谨慎。

Objective To analyze the clinical techniques ot renal artery control in laparoscoplc donor nephrectomy. Methods 211 relative living renal transplantations were performed from June 2003 to June 2012, and 136 donors underwent laparoscopic donor living nephrectomy （LDN） since 2007. Forty donors were subjected to the Hem-o-lock clips for renal artery control by open surgery, 87 donors to the Hem-o-lock clips for renal artery control by laparoscope, 5 donors to the Endo GIA stapler for renal artery control by laparoscope, and 4 donors to the Hem-o-lock clips by laparoscope combined with hand-assisted suture transfixion for renal artery control. Results The warm ischemia time of renal artery control was shortest （1.1 -＋ 0. 3 rain） by Hem-o-lock clips in open surgery, and longest （3. 2 ＋ 0. 8） min by the Hem-o-lock clips with laparoscope. There was significant difference in the warm ischemia time of renal artery between open group and other groups, the differences （P~ 0.05）. The comparison of prognostic factors in the transplant renal outcome showed no significant difference among groups. The renal arterial stump-rrhexis-caused massive secondary bleeding occurred in 1 case subject to Hem-o-lock clips for renal artery control by laparoscope, with conversion to open surgery urgently, the operation was successful at last. Other renal artery control ways were all safe without any adverse reaction. Conclusion The warm ischemia time of renal artery control by Hem-o- lock clips in open surgery was shortest in laparoscopic donor nephrectomy. The renal artery control way by Endo GIA stapler in laparoscope or by Hem-o-lock clips with hand-assisted suture transfixion is safest. The utilization of Hem-o-lock clips should be careful in high risk population such as severe atherosclerosis etc.