腹腔镜右半结肠D3根治术

Laparoscopic right hemicolectomy with D3 lymphadenectomy

介绍作者近两年来行腹腔镜右半结肠D3根治术的主要技术改进。采用五孔法完成手术,主刀站于患者两腿间手术,上腹两孔分别牵拉横结肠中段系膜及回结肠血管。显露肠系膜上静脉远端并进入血管鞘后,先沿其左侧牵开血管前腹膜并向上至显露胰颈下缘,帮助确立淋巴清扫的分离平面。通过沿筋膜层次"揭千层饼"式分离方式,可轻松显露肠系膜上动脉向前分支。动脉切断后再沿上静脉正前方处理汇入其前壁的属支,最后处理汇入其右侧壁的回结肠静脉及胃结肠干。五孔法有效牵拉横结肠系膜、首先显露胰颈确定分离平面以及"从左及右"而"非从远及近"的分离程序可有效克服肠系膜上血管的未知变异,明显提高手术的安全性及减少出血。

To recommend the improved laparoscopic skills of right hemicolectomy with D3 lymphadenectomy. Five ports were used while surgeon standing between two legs of the patient during the operation. Two ports in the right and left upper quadrants of the abdomen were employed for the exposure of the transverse colon and ileocolic vessels. At first, the superior mesenteric vessels were exposed, followed by cutting the peritoneum in front and advanced upwardly to visualize the pancreatic neck and identify the dissection plane of lymphadenectomy. Branches from the SMA which run forwardly or rightwardly were clipped and transected, allowing the exposure of the SMV. Then a left to right manner of dissection was performed with the first transecting branches to the anterior aspect of the SMV and then to the right lateral aspect of the SMV （ ileocolic vein and Henle＇ s trunk）. By using modified skills, such as five ports, exposing the pancreatic neck and use of the left to right manner of dissection instead of the distal to proximal manner could ensure an easy and safe right hemicolectomy with D3 lymphadenectomy in spite of the unknown anatomical variation.