腹腔镜下根治性肾切除手术技巧和105例经验

Operating skills of transperitoneal laparoscopic radical nephrectomy： experiences of 105 cases

目的探讨经腹腔入路腹腔镜下根治性肾切除（LRN）的手术操作技巧。方法对2008年12月至2010年12月收治的105例肾肿瘤患者采用经腹腔入路行LRN。肿瘤位于左肾51例，右肾54例，直径（5．8±2．4）cm。术前肿瘤分期为T1N0M048例，T1N0M051例T1N0M06例。术中均以生殖静脉为标志寻找肾动、静脉并依次结扎，完整切除标本后经耻骨上Pfannensteil切口取出。结果105例均成功施行经腹腔“生殖静脉标志法”LRN，28例肾上极肿瘤切除同侧肾上腺，16例加行区域淋巴结清扫。无中转开放手术者，无肝、脾、肠管等重要脏器损伤。手术时间44—78min，平均（55±11）min。术中出血量35～600ml，平均（85±26）ml。术后住院时间4～11d，平均（6±2）d。主要并发症有血管损伤3例，膈肌损伤1例，淋巴漏2例。术后临床病理分期为T，N。M。44例，T1N1M01例，T2NOM047例，T：N。M01例，T3。NoMo7例，T3N1M01例，T4NOM02例，良性病变2例。术后随访9～33个月，平均18个月，出现切口疝1例，局部复发1例，死于肺转移1例。结论经腹途径“生殖静脉标志法”LRN可准确定位、迅速结扎肾蒂大血管，术中无严重副损伤，术后恢复快、并发症少。Pfannensteil切口创伤小，符合美学要求。

Objective To discuss the operating skills of transperitoneal laparoscopic radical ne- phrectomy （LRN）. Methods From Dec 2008 to Dec 2010, 105 patients with renal tumors were treated by transperitoneal LRN. Fifty-one tumors were located in left kidney, and 54 in the right kidney. The mean diameter of renal tumor was （5.8 ~ 2.4） cm. There were 48 cases of T^NoM0, 51 of T2NoMo, 6 of T3aNoM0. During the process of transperitoneal LRN, vena genitalis was constantly used as an operative mark for seeking and ligating the renal artery and vein. The specimens were cut completely and removed through Pfannensteil incision. Results All the 105 cases were performed by transperitoneal LRN with ve- na genitalis marking method successfully. Twenty-eight cases of homolateral adrenal gland were resected and 16 cases of regional lymph node were cleaned. There was no serious injury of liver, spleen or bowels. The operating time ranged 44 - 78 min with an average of 55 min, and the blood loss was 35 - 600 ml with the mean of 85 ml. The post-operative length of stay was 4 - 11 d with an average of 6 d. Major complications included 3 cases of vessel injury, 1 case with an injury of diaphragmatic muscle and 2 cases with a lymphous leakage. Post-operative staging included 44 cases of Tl NoMo , 1 of T1N1Mo , 47 of T2NoM0 , 1 of T2N1M0 , 7 of T3NoMo , 1 of T3aN~ M0, 2 of T4NoMo, and 2 cases with benign lesion. The patients were followed up for 9 -33 months with an average of 18 months. One case had an incisional hernia, 1 had a local tumor recur- rence and 1 died of pulmonary metastasis. Conclusions Transperitoneal LRN with vena genitalis marking method could be safe for the treatment of renal tumors. The vena genitalis may act as a mark for the accurate location and quick ligation tbr the renal pedicle without serious injuries, and such patients could recover fast- ly with fewer complications. Pfannensteil incision has a good quality of little trauma and could meet with the need of aesthetics.