胸腹腔镜食管癌根治术中腹腔镜关键技术改进的单中心研究

Single center study of innovation of key technique of laparoscopy of esophagectomy with thoracoscopy and laparoscopy

目的总结胸腹腔镜食管癌根治术中腹腔镜关键技术的改进，探讨其安全性、可靠性及简便易学的实施要点。方法2014年10月至2015年2月，四川省肿瘤医院胸外科采用改进的腹腔镜关键技术完成胸腹腔镜食管癌根治手术43例，其中男性40例，女性3例；平均年龄（62．47±8．22）岁。食管癌病理分期I期者4例，Ⅱ期者16例，Ⅲ期者22例，Ⅳ期者1例；肿瘤位于胸上段12例，胸中段23例，胸下段8例。观察胸腹腔镜食管癌根治术的临床结果，总结双向胃游离技术、无抓持胃游离技术、剑突下小切口技术和胸段食管胸腔镜截取无瘤技术等腹腔镜关键技术的改进要点。结果全组围术期无死亡病例，无胸腹腔及切口种植转移，无管状胃瘘、坏死，无胃排空延迟，无腹部切口感染，无脾损伤。患者因肿瘤腹腔外侵严重而中转开腹1例（2．3％），围术期发生并发症肺部感染6例（14．0％），吻合口瘘1例（2．3％）。全组患者腹部平均手术时间（59．65±18．10）mln；腹腔操作平均出血量40（15～100）ml；病变平均最大径5（1～11）cm；腹腔清扫平均淋巴结数7（2～24）枚；重症监护室平均停留时间18（10--40）h，术后平均住院时间11（8--28）d。结论腹腔镜关键技术的改进使胸腹腔镜食管癌根治术中腹腔手术方法安全有效、简便易学。

Objective To summarize the innovation of the key technique of laparoscopy of esophagectomy with thoracoscopy and laparoscopy, and investigate its safety, reliability and feasibility. Methods For the pathological staging, 4 cases were at stageL 16 cases stage l], 22 eases stage ~ and 1 case stage IV. There were 12 eases of upper thoracic esophageal carcinoma, 23 cases of middle thoraeic esophageal carcinoma and 8 cases of lower thoracic esophageal carcinoma. The clinical outcomes were observed, and the key points of technique innovation, such as double-direction stomach mobilization, no-touch stomach mobilization, subxiphoid minimal invasion, and thoracic segment esophageal tumor-free thoracoscopic resection were summarized. Results There was no perioperative mortality, chest abdominal cavity and incision metastasis, tubular gastric fistula and necrosis, delayed gastric emptying, abdominal incision infection and splenic injury. Conversion to open surgery occurred in 1 case （2.3 % ） due to tumor invasion, pulmonary infection happened in 6 cases （14.0% ）, and anastomotic fistula took place in 1 ease（2.3 %）. The mean abdominal operation time was （59.65 ± 18.10） min, the mean volume of blood loss was 40 rnl （15 to 100 ml）, the mean maximum diameter of lesions was 5 cm（1 to 11 cm）, the mean abdominal lymph node number was 7 （2 to 24）, the mean duration of ICU stay was 18 h（10 to 40 h）, and the mean postoperative hospital stay was 11 d（8 to 28 d）. Condmion Innovation of the key technique of laparoscopy of the esophagectomy with thoracoscopy and laparoscopy is safe, effective, convenient and easy to learn.