两孔法腹腔镜远端胃癌根治术的初步经验

Preliminary experience of dual-port laparoscopic distal gastrectomy for gastric cancer

目的探讨两孔法腹腔镜远端胃癌根治术(DPLDG)的近期疗效及美容效果。方法南方医科大学南方医院普通外科2016年11月至2018年8月对连续收治拟行远端胃癌根治术的30例患者进行了DPLDG。病例纳入标准:(1)年龄18~75岁;(2)活体组织病理学检查证实为胃腺癌;(3)肿瘤位于胃中下部,拟行远端胃癌根治术;(4)术前肿瘤临床分期为cT1b^T2N0~N1M0;(5)肿瘤直径≤3cm;(6)美国东部肿瘤协作组评分(ECOG)0~1分;(7)美国麻醉医师协会分级为Ⅰ~Ⅱ级;(8)按加速康复外科(ERAS)流程行围手术期处理。排除既往有上腹部手术史(胆囊切除术除外)、合并其他恶性肿瘤以及体质指数≥30kg/m^2者。使用自主研发的单孔多通道操作装置(厦门,施爱德;3个通道分别作为观察孔、主刀主操作孔和助手操作孔)于脐下或左侧绕脐取3~4cm切口置入;于右侧锁骨中线肋缘下置入5mm戳卡,作为副操作孔及引流管位置;悬吊肝脏。手术步骤:使用常规腹腔镜操作器械,进入网膜囊后,沿横结肠往脾曲游离,于根部结扎胃网膜左血管,清扫No.4sb淋巴结;沿胃大弯清扫No.4d淋巴结;沿横结肠继续游离,分离胃系膜和横结肠系膜,于根部结扎胃网膜右动脉,清扫No.6淋巴结;用直线切割闭合器离断十二指肠球部,于根部结扎胃右动脉并清扫No.5淋巴结;在胰腺上缘胰后间隙游离腹腔干、肝总动脉、脾动脉和胃左动静脉,结扎胃左血管,清扫No.9、No.8a、No.11p及No.7淋巴结;显露门静脉左侧壁,清扫No.12a淋巴结;沿胃小弯游离清扫No.1、No.3淋巴结;于肿瘤近端4~5cm用直线切割闭合器离断胃体,在腔内行Roux-en-Y吻合或Billroth Ⅱ式吻合;经右上腹副操作孔于胃空肠吻合口附近留置1根引流管。观察分析30例患者的近期疗效(包括手术时间、术中出血量、增加戳孔率、中转开腹率、淋巴结检出数目、术后首次排气时间、术后首次进食流质饮食时间、术后拔除引流管时间、术后住院时间、追加使用镇痛药物率及术后30d内并发症发生率等)和美容评分(患者自评,分别为伤口瘢痕满意程度评分、伤口瘢痕评分和伤口瘢痕分级,总分数最低3分,最高24分,评分越高,美容效果越好)。结果全组患者手术过程中未发生严重并发症,无死亡病例。手术时间为(197.8±46.9)min,术中出血量中位数30(四分位间距为31.25)ml,淋巴结检出数目为(38.7±14.1)枚,增加戳孔率为3.3%(1/30),无中转开腹手术。术后首次排气时间为(45.3±18.9)h,首次进食半流质饮食时间为(87.6±35.6)h,拔除引流管时间为(101.8±58.0)h;80.0%(24/30)的患者不需要追加使用镇痛药物,术后住院时间为(6.1±2.1)d。术后30d并发症发生率为16.7%(5/30),分别为腹腔出血、淋巴漏和肠梗阻各1例以及腹腔感染2例。全组患者术后美容评分(22.1±1.3)分,96.7%(29/30)的患者美容评分18~24分。结论DPLDG安全可行;对于患者的术后恢复、减轻疼痛及美容具有优势。

Objective To evaluate the short-term efficacy and cosmetic effect of dual-port laparoscopic distal gastrectomy(DPLDG)for gastric cancer.Methods Thirty consecutive patients underwent DPLDG at the Department of General Surgery,Nanfang Hospital from November 2016 to August 2018.Inclusion criteria:(1)age of 18 to 75 years;(2)primary gastric adenocarcinoma confirmed pathologically by endoscopic biopsy;(3)tumor located at middle-low stomach and planned for distal gastrectomy;(4)cT1b-2N0-1M0 at preoperative staging;(5)tumor diameter≤3 cm;(6)US Eastern Cancer Cooperative Group(ECOG)score 0 to 1 points;(7)American Society of Anesthesiologists grade Ⅰ to Ⅱ;(8)perioperative management based on enhanced recovery after surgery(ERAS)principle.Exclusion criteria: previous upper abdominal surgery(except laparoscopic cholecystectomy),history of other malignant disease,and body mass index≥30 kg/m^2.A self-developed single-incision,multiport,laparoscopic surgery Trocar(Surgaid Medical,Xiamen,China,comprising 3 channels for observation,main surgeon and assistant surgeon)was placed through a 3-4 cm incision under or at the left side of the umbilicus.An additional 5 mm Trocar was inserted under the rib margin of the right clavicle to serve as the secondary operating hole and the position of the drainage tube.The liver was suspended to expose the surgical field clearly.Surgical procedure was as follows: conventional laparoscopic instruments were used.After entering the omental sac,dissection was performed along the transverse colon to the spleen flexure.Left gastroepiploic vessels were identified and then ligated at the root.No.4sb lymph nodes were dissected.The No.4d lymph nodes were dissected along the greater curvature of the stomach.Then the dissection was continued rightward to the hepatic flexure to separate mesogastrium and mesocolon.The right gastroepiploic artery was ligated at the root to allow the removal of No.6 lymph nodes.The duodenal bulb was transacted by liner stapler,the right gastric artery was ligated at the root and the No.5 lymph nodes were removed.Peritoneal trunk,common hepatic artery,splenic artery and left gastric artery and vein in posterior pancreatic space at upper pancreas were separated,then left gastric vessels were ligated,and No.9,No.8a,No.11p and No.7 lymph nodes were dissected.The left side wall of portal vein was exposed and No.12a lymph nodes were removed.No.1 and No.3 lymph nodes were dissected along the lesser curvature.The stomach corpus was transacted by liner stapler at 4-5 cm proximal end of the tumor.Roux-en-Y anastomosis or Billroth II anastomosis was performed in the cavity.A drainage tube was placed near the gastrojejunal anastomosis through the right upper abdomen secondary operating hole.Postoperative short-term efficacy(operation time,blood loss,5-port conversion rate,open conversion rate,number of retrieved lymph nodes,time to postoperative first flatus,time to first soft diet intake,time to removal of drainage tube,postoperative hospital stay,postoperative analgesics use,and postoperative 30-day complication rate)and cosmetic scale(questionnaire: degree of satisfaction with scar,description of scar,grade of scar;total score ranged from the lowest 3 to the highest 24;the higher the better)were evaluated in all 30 patients.Results No serious complication and death were observed intraoperatively.The mean operative time was(197.8±46.9)minutes.The median blood loss was 30 ml(quartile 31.25 ml).The mean number of retrieved lymph node was 38.7±14.1.Five-port conversion rate was 3.3%(1/30),and no open conversion occurred.Mean time to postoperative first flatus,time to first soft diet intake,time to removal of drainage tube and postoperative hospital stay were(45.3±18.9)hours,(87.6±35.6)hours,(101.8±58.0)hours and(6.1±2.1)days,respectively.Twenty-four(80%)of patients had no additional analgesics use.The postoperative complication rate within 30 days was 16.7%(5/30).Postoperative overall cosmetic score was 22.1±1.3,and cosmetic score of 96.7%(29/30)of patients was 18 to 24.Conclusion DPLDG is safe and feasible with advantages of faster postoperative recovery,reducing pain and better cosmetic outcomes.