单操作孔、单孔全胸腔镜肺叶切除术的临床应用

Single utility port or single port complete video-assisted thoracoscopic surgery for pulmonary lobectomy

目的 探讨单操作孔、单孔胸腔镜手术（VATS）分别在全胸腔镜上肺叶切除术及中下肺切除术中的临床应用.方法 回顾性分析武汉大学人民医院胸外科2013年6月至2014年12月收治的191例单操作孔、单孔VATS肺叶切除患者的临床资料,上叶切除采用单操作孔VATS手术,中、下叶切除采用单孔VATS手术.结果 191例患者中行左肺上叶切除35例,左肺下叶切除42例,右肺上叶切除43例,右肺中叶切除11例,右肺下叶切除47例,右肺中下叶切除13例.所有患者手术过程顺利,术中3例因胸膜粘连致密或大出血等原因中转开胸.上叶单操作孔VATS术中有7例患者、中下叶单孔VATS有8例患者因术中胸膜粘连等原因各加1个辅助操作孔.手术时间50～190（80.3±43.2）min,术中出血量90～ 350（145.4±56.2）ml.上肺切除患者78例,术后均留置2根胸管,上胸管拔除时间（1.5±0.8）d,下胸管拔除时间（4.2±1.3）d;中、下叶切除患者113例,术后均留置1根胸管,胸管拔除时间（4.0±1.7）d.所有患者术后住院时间（6.1±2.5）d.每例患者清除淋巴结（14.7±6.9）枚.良性病变患者21例,肺癌患者170例.TNM分期：ⅠA期67例,ⅠB期61例,ⅡA期34例,ⅡB期22例,ⅢA期7例.围手术期无支气管胸膜瘘、死亡等严重并发症.结论 鉴于上肺叶切除术后常规留置上、下两根胸管,中下叶切除术后留置一根胸管,笔者认为上叶切除采用单操作孔（2孔）VATS、中下肺叶切除采用单孔VATS手术安全、可行,有利于患者术后引流、恢复,手术时间、并发症率及清扫淋巴结数量均与常规3孔VATS肺叶切除术无明显差异,患者术后恢复更快、疼痛更轻.

Objective To explore clinical application of single utility port or single port video-assisted thoracoscopic lobectomy.Methods Conducting a prospective study to 191 patients with lung disease who underwent complete video-assisted thoracoscopic surgery （VATS） lobectomy in Department of Thoracic Surgery of The People＇s Hospital of Wuhan University from June 2013 to Dec 2014.Results Of the 191 patients, 35 underwent left upper lobectomy, 42 underwent left lower lobectomy, 43 underwent right upper lobectomy, 11 underwent right middle lobectomy, 47 underwent right lower lobectomy, and 13 underwent bilobectomy.Operations were successful in all patients with 3 patients transferred for open thoracotomy for severe adhesion or bleeding.A total of 7 of 78 upper lobectomy and 8 of 113 middle or lower lobectomy was done with adding another incision for severe adhesion.The mean operative time was 50 ～ 190 （80.3 ±43.2） min.The mean blood losing was 90 ～ 350 （145.4 ± 56.2） ml.Thirty nine patients underwent upper lobectomy, who were placed two chest tubes, respectively.The upper chest drainage duration was （1.5 ±0.8） d, and the lower chest drainage duration was （4.2 ± 1.3） d.Forty eight patients underwent lower lobectomy, middle lobectomy, or bilobectomy, who were placed one chest tube, respectively.The chest drainage duration was（4.0 ± 1.7）d.The mean recovery time after operation was （6.1 ± 2.5） d.Seventy six patients were diagnosed with lung cancer, and the average number of dissected lymph nodes from each patient was （14.7 ±6.9）.The lung cancer was classified as tumor node metastasis （TNM） stage Ⅰ A, Ⅰ B,ⅡA, ⅡB and ⅢA in 67, 61, 34, 22 and 7 cases, respectively.No serious complications, such as bronchopleural fistula or death, occurred in perioperation.Conclusions In consideration of placing two chest tubes after upper lobectomy and placing one chest tube after lower lobectomy, middle lobectomy, or middle and lower lobectomy, we think single utility port-VATS （2-port） for upper lobectomy and single port-VATS lobectomy for lower lobectomy, middle lobectomy, or middle and lower lobectomy are technically safe and have the advantages of drainage, lessening pain, rapid postoperative recovery, and have no significant difference in operation time, the incidence of complications and the number of removed lymph nodes, compared to traditional 3-port-VATS.