腔镜下食管癌切除术游离胃的方法探讨

Laparoscopic Mobilization of Stomach in Minimally Invasive Esophagectomy

目的：总结腔镜下食管癌切除术中腹腔镜游离胃的方法。方法选取2010年1月～2012年12月我科单治疗组50例术前病理证实为食管鳞癌行腔镜下食管癌切除术，腹腔镜游离胃，以胃左动脉为定位，分为先游离胃左动脉组和后游离胃左动脉组各25例。全腔镜下食管癌切除40例；腹腔镜游离胃，胸腔镜辅助右侧小切口食管癌切除10例。比较2组手术时间、出血量和胃壁受损情况。结果均在腹腔镜下完成胃的游离，无中转开腹。与后游离胃左动脉组相比，先游离胃左动脉组游离胃的时间短[21～62 min（中位数34 min） vs．28～130 min （中位数53 min）， Z＝-4．786， P＝0．000]，出血少[5～110 ml（中位数45 ml） vs．20～2000 ml （中位数150 ml）， Z＝-5．425， P＝0．000]，胃壁无创钳牵拉处充血点少[0～4处（中位数2处） vs．1～10处（中位数6处）， Z＝-5．517， P＝0．000]。结论腔镜下食管癌切除术中腹腔镜游离胃时，首先游离小网膜及胃左动脉，沿胰腺平面游离胃后至胃脾韧带脾后端处，然后游离胃大网膜向胃脾韧带处用超声刀离断，最后打开膈食管裂孔与胸腔相通。这是一种比较安全、快捷、对胃壁损伤较小的方法，值得推广。

Objective To investigate the feasibility, safety and efficacy of laparoscopic mobilization of stomach in minimally invasive esophagectomy （ MIE ） . Methods A total of 50 patients with esophageal squamous carcinoma underwent laparoscopic mobilization of stomach from January 2010 to December 2012 in our department.All patients were divided into two groups：mobilization of left gastric artery in the beginning of surgery （25 cases, group 1）;mobilization of left gastric artery in the later time of surgery （25 cases, group 2）.Of the 50 patients, 40 underwent MIE and 10 had only laparoscopic mobilization of stomach. Results All the patients were performed under laparoscopy for successful gastric mobilization.As compared with the group 2, the group 1 had significantly shorter abdominal operation time [21-62 min （median, 34 min） vs.28-130 min （median, 53 min）, Z=-4.786, P=0.000], less blood loss during the operation [5-110 ml （median, 45 ml） vs.20-2000 ml （median, 150 ml）,Z=-5.425, P=0.000], and less gastric injury points [0-4 （median, 2） vs.1-10 （median, 6）, Z=-5.517, P=0.000]. Conclusion In laparoscopic mobilization of stomach in MIE, early mobilization of left gastric artery shows shorter abdominal operation time, less blood loss during the operation, less gastric injury points, being a valuable procedure.