食管微创解剖特点在食管癌三野清扫中的应用

Anatomy of mesoesophagus in esophagectomy with minimally invasive three-fields lymphadenectomy

目的 探讨食管及其周围结构的微创解剖特点在胸腹腔镜下食管癌三野淋巴结清扫术中的应用.方法 回顾性分析2011年7月至2012年9月间汕头市中心医院收治的67例食管癌患者的临床资料,所有病例均行三野淋巴结清扫术,根据食管系膜的微创解剖学特点选择恰当的操作平面;胸腔镜下以奇静脉为界,将操作空间分为上、下食管三角；胰腺是腹腔镜下胃游离的关键解剖标志,胰周间隙是腹腔镜手术和天然外科平面；椎前筋膜是颈部清扫的底面,两侧则以颈动脉鞘为界.结果 全组手术时间220～320（平均251.6）min,术中出血量为40～320（平均105.6）ml.共清扫淋巴结1949枚,每例13～46（平均 29.1）枚,其中胸区淋巴结平均15.1枚/例,腹区8.2枚/例,颈区5.8枚/例.无围手术期死亡病例.术后随访2～14（平均8.2）月,随访率 98.5％（66/67）,受访患者均存活,出现反流性食管炎10例,吻合口狭窄3例.结论 建立腔镜下整体解剖观念、明确食管系膜的解剖层面和镜下定位,有助于提高腔镜食管癌根治术的安全性和根治性.

Objective To explore the anatomic features of mesoesophagus in combined thoracoscopic and lapamscopic esophagectomy with three-fields lymphadenectomy.Methods Clinical data of 67 patients undergoing thoracoscopic and laparoscopic esophagectomy with three-fields lymphadenectomy from July 2011 to September 2012 were analyzed retrospectively.All the patients underwent three-fields lymphadenectomy.Proper surgical planes were selected according to anatomy of mesoesophagus.Thoracoscopic surgical space was bounded on azygotic vein and divided into upper and low esophageal triangle.Pancreas was the key anatomical mark for laparoscopic gastric dissection,and peripancreatic space was the natural laparoscopic surgical plane.Prevertebral fascia was bottom surface of neck dissection and carotid sheath was the boundary of two sides.Results The median operative time was 251.6 min（range,220 to 320 min）.The median operative blood loss was 105.6 ml （range,40 to 320 ml）.The median number of lymph nodes dissected was 29.1 （range,13 to 46,totally 1949）.There was no perioperative death.Sixtysix patients were followed up with a mean follow-up time of 8.2 months （range,2 to 14 months）.Postoperative complications included reflux esophagitis in 10 and anastomotic stenosis in 3 cases.Conclusion It is safe and more radical for minimally invasive esophagectomy that overall concept of minimally invasive anatomy of mesoesophagus is applied to identify the anatomic plane and landmark during operation.