经脐单孔腹腔镜肾切除术的技术改进

Technical improvement of transumbilical laparoendoscopic single-site nephrectomy

目的:总结经脐单孔腹腔镜肾切除术的技术改进及经验体会。方法:回顾性分析2010年6月至2013年4月行经脐单孔腹腔镜肾切除术的临床资料,根据技术特点与手术日期分为两组,第一阶段自2010年6月至2011年4月(组1),其中10例为根治性肾切除术,2例为无功能肾切除术;第二阶段自2011年5月至2013年4月行技术改良的经脐单孔腹腔镜肾切除术(组2),其中7例为根治性肾切除术,3例为无功能肾切除术。通过技术与装置的改进,如:应用单环装置、术中快速寻找到肾蒂、用腹壁悬吊技术来解决肝脏的遮挡等,切除标本后置入取物袋,在脐部切口与单孔装置一并取出。结果:手术均顺利完成,无中转开腹者。组1中有2例中转为传统腹腔镜手术,1例中转为手助腹腔镜手术;组2有1例加1枚辅助穿刺套管(Trocar)。组2相比组1手术时间缩短[(178.9±34.0)min vs.(220.6±51.0)min,P=0.04]。所有患者无血肿、感染、肠梗阻、切口疝等并发症。术后随访2至36个月,肿瘤无复发。结论:经脐单孔腹腔镜肾切除术技术要求高,易出现严重并发症,通过技术改进,可以缩短手术时间与学习曲线,减少并发症的发生。

Objective：To summarize the technical modification and experiences of transumbilical laparoendoscopic single-site nephrectomy（LESS-N） by homemade device.Methods： The clinical data of LESS nephrectomy performed from June 2010 to April 2013 in Peking University Third Hospital were analyzed retrospectively.All the cases were divided into two groups according to the technique method and operative date.Group 1 included 10 cases that underwent LESS radical nephrectomy and 2 that received LESS simple nephrectomy from June 2010 to April 2011.Group 2 included 7 cases that underwent LESS radical nephrectomy and 3 that received LESS simple nephrectomy from May 2011 to April 2013.The data on the general presentation,tumor size,tumor location,operative time,blood loss,complications,Visual Analog Pain Scale（VAPS）,postoperative hospital stay,pathological results were collected to compare between the two groups.The modified technique included homemade single-ring glove technique,fast access to the pedicle,pulling-up technique to retract the kidney or liver.The kidney was dissociated after the renal vessel was cut off and extracted through the umbilical incision.Results： All the procedures were finished without conversion to open radical nephrectomy.Compared with group 1,operative time showed significant difference in group 2 [Group 1：（220.6±51.0） min;Group 2：（178.9±34.0） min;P=0.04],and no difference was noted in other factors（P＆gt;0.05）.There was no secondary bleeding,wound infection,intestinal obstruction,incision hernia and other severe postoperative complications.Follow-up of 2 to 36 months showed no local recurrence.Conclusion： Transumbilical LESS-N is feasible,effective and safe.It gives a more mini-invasive and cosmetic option for young or female patients.Learning curve and operative time can be reduced by modified techniques,such as single-ring glove technique and pulling-up technique.