自制经脐单孔腹腔镜套管下根治性膀胱切除和尿流改道术的初步体会

Laparoendoscopic single.site radical cystectomy and urinary diversion： initial experience using homemade single-port device

目的探讨自制经脐单孔腹腔镜套管下根治性膀胱切除和尿流改道术的临床效果。方法选取2010年12月到2011年4月收治的膀胱癌患者7例，均为男性。年龄54～81岁，平均66岁。体质指数（body mass index，BMI）20．9～25．3kg／m2，平均23．1kg／m2。全麻下采用自制经脐单孔腹腔镜套管行根治性膀胱切除和尿流改道术，术中经脐旁正中5cm皮肤切口置入由聚碳酸酯倒锥形装置和无菌外科手套组成的自制单孔腹腔镜套管，传统的腹腔镜器械经该套管置入进行操作。根据患者情况，尿流改道方式分别为输尿管皮肤造口术3例和回肠膀胱术4例。分析手术时间、术中出血量、术后恢复时间、肿瘤学资料及术后并发症。结果本组7例手术均顺利完成，无中转常规腹腔镜手术或开放手术，术中未使用额外的手术孔道。根治性膀胱切除时间为155～280min，平均210min；出血量为100～500ml，平均300ml；胃肠功能恢复时间为4～12d，平均8d；术后住院时间为13～34d，平均20d。1例术中输悬浮红细胞400ml。术后病理诊断：T1N0M01例、T2aN0M02例、T2bN0M02例和T3cN0M02例；高分级4例，低分级3例；标本切缘均为阴性。1例术后3d出现肠梗阻，予禁食、补液及胃肠减压治疗后好转；1例术后1d死于心肌梗死。6例随访34～139d，平均为89d。无肿瘤复发，患者对手术的美容效果满意，无切口感染、切口疝等并发症。结论单孔腹腔镜下根治性膀胱切除和尿流改道术治疗肌层浸润性膀胱癌患者安全可行，有明显的学习曲线。自制单孔腹腔镜套管使用方便，价格低廉。

Objective We report our initial experience with laparoendoscopic single-site surgery （LESS） for radical cystectomy and urinary diversion performed by a single surgeon using homemade singleport device. Methods From December 2010 and April 2011, 7 LESS radical cysteetomy were performed using a home-made single-port device composed of an inverted cone device of polycarbonate and a powderfree surgical glove. 7 patients were all male, mean age was 66 （54 -81 ） years and mean BMI （Body mass index） was 23.1 （20.9 -25.3） kg/m2. The port was placed into a 5 cm periumbilical skin incision. The conventional laparoscope and laparoscopic instruments were inserted through the single-port. No additional ports were needed for radical cystectomy and bilateral standard pelvic lymphadenectomy. Cutaneous ureteros- tomy （3 cases） and ileal conduit urinary diversion （4 cases） were used for patients. Operative time, esti- mated blood loss, postoperative recovering time, oncologic data and complications were collected and analyzed. Results All the procedures were completed successfully. The mean operative time was 210. 1 （ 155 - 280） minutes. The estimated blood loss was 300 （ 100 - 500） ml. The bowel recovering time 8 （4 - 12） days and postoperative hospital stay was 20 （13 -34） days. One patient required a transfusion of 400 ml red blood cells. The pathologic evaluation revealed that there were one case of pT1NoMo, two of pT2aN0M0 , two of pTEbN0M0 and two of pT3aN0M0. The high grade tumor in 4 cases and low grade in 3 cases. The surgical margins were negative in all the patients. All patients were node negative. After the operations, one case had a small bowel obstruction after three days and was treated by abrosia, fluid infusion and gastrointestinal decompression. Another patient died of cardiac disease at first day postoperative. Conclusions In our experience, LESS for radical cystectomy could be clinically feasible for selected patients, but it requires the learning curve.