腹腔镜低位直肠癌保肛手术的操作技巧(附33例报告)

The operation skill of laparoscopic anus-preserving operation for low rectal cancer: with a report of 33 cases

目的：探讨腹腔镜低位直肠癌保肛手术的适应证及操作技巧。方法：回顾分析33例肛缘≤7cm直肠癌患者的临床资料。利用腹腔镜下低位、超低位或经肛门直肠拖出外翻技术完成根治并结、直肠吻合，总结其手术适应证、手术技巧及相关体会。结果：32例手术获得成功，1例直肠下切缘肿瘤阳性改行Miles术。测量离体标本肿瘤至下切缘距离，20例≥2．0cm，12例为1．9～1．0cm。Dukes分期：A期7例、B期19例、C期6例。手术时间平均（170±55）min。术后第10天发生下肢深静脉血栓1例，经抗凝与活血化瘀治愈。发生吻合口漏1例，经骶前双套管引流治愈。术后2年发现左锁骨上淋巴结转移性腺癌1例，目前1：2服加静脉化疗，至今术后4年生存良好。1、3、5年生存率为100％（32／32）、80．0％（16／20）、75．O％（9／12），Trocar及辅助切口未发生肿瘤种植，局部无复发。结论：腹腔镜低位直肠癌保肛术适于DukesA、B期及无肠道梗阻的C，期患者，前提是下切缘阴性及不破坏肛门括约肌功能，以牺牲根治换取微创、保肛是不可取的。腹腔镜低位直肠癌保肛术具有解剖清晰、容易分离至肿瘤远端、患者创伤小、康复快等优点。因完成例数较少，随访时间短，远期效果尚需大样本、多中心临床资料对比。

Objective：To discuss the indications and skills of laparoscopic anus-preserving operation for low rectal cancer. Methods ： The clinical data of 33 patients with rectal cancer within 7 cm from anal verge were collected and analyzed. The patients un- derwent laparoscopic radical operation, low or uhra-low or transanal endorectal pull-through colorectal anastomosis. The experience of surgical indications and skills was summarized. Results ： One patient received Miles surgery because cancer cel｜s were detected in the lower distal margin, while the other 32 cases were successfully performed operations as originally planned. The distance from the lower border of tumor to the distal margin of rectum was measured in vitro,it was more than 2.0 cm in 20 cases,and in 12 cases,the value was 1.0-1.9 cm. There were 7 patients with Dukes A,19 with Dukes B and 6 with Dukes C. The operation time on average was （ 170 ＋ 55 ） min. One patient suffered from deep venous thrombosis at the 10th day after surgery and then recovered by anti-coagulating and ac- tivating blood stasis. Anastomotic fistula occurred in another patient and finally been cured by presacral bitube drainage. After 2 years of follow-up, a patient was noticed with left supraclavicular lymph node metastasis. On account of oral and intravenous chemotherapy, he was still alive 2 years later. The 1,3,5 year survival rates were 100% ,80% ,75% respectively. There was no incision implantation or local recurrence. Concluslons：Laparoscopic anus-preserving operation for low rectal cancer is suitable for the patients with Dukes A, Dukes B, as well as Dukes C1 without intestinal obstruction,on condition that there is no cancer cell in the distal margin and no harm to anal sphincter function. It is inadvisable to achieve the goal of minimal invasion and anus preservation at the expense of eradication. Laparoscopic anus-preserving operation for low rectal cancer has the advantages of clear anatomical structure, handiness, mini-invasion, rapid recovery and so on. However, the study is very small,with a small number of patients and rather short-term following up, so long- term effect still needs to be further evaluated and compared with large-sample, multi-center clinical data.