经腹腹腔镜肾切除手术的肾蒂处理技术:单一术者191例经验总结

Technique of renal pedicle control in transperitoneal laparoscopic nephrectomy:experience of 191 cases by a single surgeon

目的：探讨经腹腹腔镜肾切除手术中肾蒂处理的手术操作技巧.方法：2010年5月至2013年9月,北京大学第一医院泌尿外科由同一术者进行的经腹入路腹腔镜肾切除手术191例,其中肾癌根治术116例,肾输尿管全长切除术57例,单纯肾切除术18例.采用改良4套管技术,助手将肾下极挑起,从肾下方及背侧方向进镜观察,部分借鉴腹膜后入路的观察角度,可以明显改善肾动脉显露,采用带锁血管夹（Hem-o-lock夹）或腹腔镜用直线切割缝合器处理肾蒂血管.T2期以上肾癌患者同时行同侧肾门区域淋巴结清扫.结果：190例手术顺利完成,手术时间为74 ～352 min,平均171.5 min.术中失血量5～1 000 mL,平均94.8 mL;1例因肿瘤侵及结肠,分离困难转为开放手术.主要并发症有血管损伤5例,均在腔镜下处理;脑梗死合并急性肾损伤1例;术后肺部感染2例.术后平均住院5.6（2 ～19）d.无围手术期死亡.结论：改良肾蒂处理技术可改善经腹腹腔镜肾切除中的肾蒂血管显露,增加手术安全性,缩短手术时间.

To explore the technique of vascular control in transperitoneal laparoscopic ne- phrectomy. Methods： From May 2010 to September 2013, 191 consecutive transperitoneal laparoscopic nephrectomies were performed by a single surgeon. The operations included 116 radical nephrectomies, 57 nephroureterectomies, and 18 simple nephrectomies. Improved 4-trocar method was applied. Through lifting up inferior pole of the kidney by an assistant, and observing renal vascular from the bottom or back of the kidney, the exposure of renal vessels were improved. The renal vessels were managed with Hem-o- lock or Endo GIA. For tumors of stage I〉 T2, ipsilateral lymph node dissection of renal hilus was per- formed. Results： Of the entire 191 cases, 190 were performed successfully, only 1 converted to open sur- gery because of the difficulty in separating the tumor from the invaded colon. The average time of opera- tion was 171.5 rain （74 -352）. The blood loss was 5 - 1 000 mL with an average of 94.8 mL. The complications included vascular injuries （5 cases） , cerebral infarction accompanied by acute renal injury （ 1 case）, and pulmonary infection （2 cases）. The mean postoperative hospital stay was 5.6 days （2 - 19 days）. No perioperative death occurred. Conclusion： The reformative technique of vascular control could improve the exposure of renal vessels, increase surgery safety, and shorten the time of transperito- neal laparoscopie nephrectomy.