保留脾和幽门的腹腔镜全胰十二指肠切除术1例报告

Laparoscopic Total Pancreatoduodenectomy with Pylorus and Spleen Preservation: a Case Report

目的：探讨完全腹腔镜下保留脾和幽门的全胰十二指肠切除术的安全性与可行性。方法2013年1月，对1例胰腺多发囊腺瘤合并右肾细胞癌患者行腹腔镜下保留脾和幽门的全胰十二指肠切除联合右肾切除术。腹腔镜器械四孔入路，打开胃结肠韧带、游离胰腺下缘并显露肠系膜上静脉，应用超声刀、组织剪及吸引器锐性和钝性解剖相结合分离胰腺钩突与肠系膜上静脉，沿脾动静脉向左侧胰尾部游离并结扎其分支，解剖肝十二指肠韧带，切断胆总管，应用腔镜切割吻合器距幽门约5 cm处及胰头下缘2 cm处切割闭合十二指肠，将整个胰腺及部分十二指肠切除，消化道胆道重建采用Roux-en-Y吻合。游离右肾，闭合右肾动静脉及输尿管，切除后右肾与胰腺标本从脐下扩大切口取出。结果手术顺利完成，手术时间7．5 h，术中出血约1100 ml，术后无胆肠吻合口漏等并发症，术后15天出院，随访6个月，血糖控制在4～14 mmol/L，无肾肿瘤复发转移。结论腹腔镜下保留脾和幽门的全胰十二指肠切除术可行、安全，手术方法有待更多经验积累及随机临床论证。

Objective To assess the feasibility and safety of laparoscopic total pancreatoduodenectomy with pylorus and spleen preservation . Methods One patient undergoing laparoscopic pylorus-and spleen-preserving total pancreatoduodenectomy and nephrectomy in our hospital in January 2013 was studied.Laparoscopic instruments were introduced by four-hole method.Firstly, the gastrocolic ligament was opened .Then the lower edge of the pancreas was mobilized to expose the superior mesenteric vein .The uncinate process and the superior mesenteric vein were separated with sharp and blunt exploration by application of ultrasonic scalpel , surgical scissors and suction .Branches of the splenic artery and vein were ligated at distal pancreas .The hepatoduodenal ligament was isolated, and the common bile duct was cut off .The duodenum was removed and closed at about 5 cm away from the pylorus and 2 cm from the lower edge of the pancreatic head , respectively , by ENDO RLC.The total pancreas and part of the duodenum were removed . Gastrointestinal and biliary reconstruction were performed by using the Roux-en-Y method.The right kidney was freed and the right renal vessels and ureter were closed .After the removal , the kidney and pancreas were extracted through the enlarged trocar site at belly button. Results The operation was completed successfully .The operation time was 7.5 hours and the blood loss was about 1100 ml.No postoperative biliary-enteric anastomosis leakage or other complications occurred .The patient was discharged from hospital 15 days after surgery .During 6 months of follow-up, the blood glucose was controlled at 4-14 mmol/L, and no evidence of tumor relapse was found . Conclusion It can be inferred from this case that laparoscopic total pancreatoduodenectomy with pylorus and spleen preservation is a feasible and safe procedure .