两种皮下通路腹腔镜腹股沟淋巴结清扫术在外阴癌治疗中的对比观察

Video endoscopic inguinal lymphadenectomy via hypogastric/limb subcutaneous approach for early-stage vulvar cancer

目的比较经下腹部皮下通路与下肢皮下通路两种不同途径腹腔镜腹股沟淋巴结清扫术在外阴癌手术治疗中的可行性和安全性。方法2011年3月至2013年8月对南方医科大学珠江医院妇产科7例外阴鳞癌患者，施行了腹腔镜腹股沟淋巴结清扫术（VEIL）。其中，一侧采用下腹部皮下通路（VEIL—H）术式，另一侧采用下肢皮下通路（VEIL-L）术式。清扫范围包括腹股沟浅深淋巴组织，手术同时行改良广泛外阴切除术。比较分析两种不同通路的手术技巧和近期手术效果。结果对7例均同时成功施行了VEIL—H与VEIL-L的联合术式以及改良广泛外阴切除术。平均手术时间、平均出血量、淋巴结清扫数目方面的差异无统计学意义。术后引流管放置时间：VEIL—H侧（4．7±1．4）d、VEIL—L侧（2．7±0．9）d，差异有统计学意义（P〈0．01）；术后引流量：VEIL．H侧（123±55）ml、VEIL—L侧（62±32）ml，差异有统计学意义（P〈0．05）；术后平均住院时间为（8．6±2。2）d；两种术式伤口均为甲级愈合；术中术后均无严重并发症，VEIL-H侧术中损伤大隐静脉1例；VEIL-H侧术后腹股沟淋巴囊肿1例，经治疗后痊愈；VEIL—L侧淋巴渗漏1例，加压包扎后自然痊愈；随访（19±7）个月，未见肿瘤复发。结论两种微创通路均可安全施行外阴癌腹股沟浅深淋巴结清扫。VEIL-L术式在清扫腹股沟深淋巴结时相对容易暴露，而VEIL-H在需要行盆腹腔手术时则更为方便和微创。

Objective To describe and compare video endoscopic inguinal lymphadenectomy via hypogastric and limb approach （VEIL-H vs VEIL-L） in patients with invasive vulvar cancer. Methods From March 2011 to August 2013, 7 women with early-stage vulvar cancer were selected for this integrated procedure with a combination of VEIL-H and VEIL-L in bilateral groins. VEIL-L was performed on limb with old surgical scar in ipsilateral hypogastric area of 3 patients and VEIL-H in contralateral limb. Both novel procedures were performed with triple trocars respectively. The boundaries of inguinal lymph node dissection were the same template of open inguinal lymphadenectomy. Preoperative data, surgical techniques and follow- up outcomes were compared. Standard statistical tests were used. Results The combination of VEIL-H and VEIL-L was successfully completed in 7 patients without conversion into open surgery. The great saphenous vein was spared in 13 limbs. No difference existed in mean operative duration, average blood loss volume and median total regional lymph nodes removed in two groups. All nodes were confirmed tumor-free. Mean drain duration was （4. 7 ± 1.4） days in the VEIL-H group and （2. 7 ±0. 9） days in VEIL-L group respectively （P 〈 O. 01 ）. Mean drain volume was （ 123 ±55） ml in VEIL-H group and （62 ± 32） ml respectively （ P 〈 0. 05）. Mean postoperative hospital stay was （8.6 ± 2. 2 ） days. No major intraoperative complications occurred. However, hypercarbia in one patient 1 was completely reversible with hyperventilation. Unilateral great saphenous vein was injured in another one. Regarding postoperative complications, one patient suffered lymphocele in VEIL-H side and another had lymphorrhea through drain orifice in VEIL-L side. During a follow-up period of （19±7） months, there was no disease recurrence so far. Conclusion The combination of VEIL-H and VEIL-L has the reproducibility and therapeutic potentials in the treatment for patients with vulvar cancer. Both minimal invasive techniques are viable. Although short-term results are encouraging, larger series with a longer follow-up are required to fully evaluate the therapeutic efficacy of VEIL-H and VEIL-L.