改良经脐单孔腹腔镜下单纯性肾切除术的安全性和可行性

Safety and feasibility of modified transumbilical laparoendoscopic single-site simple nephrectomy

目的 探讨改良经脐单孔腹腔镜下单纯性肾切除术的安全性和可行性.方法 回顾性分析2012年6月至2014年2月15例行经脐单孔腹腔镜下单纯性肾切除术（A组）和2014年2-12月10例行改良经脐单孔腹腔镜下单纯性肾切除术（B组）患者的临床资料.A组：男8例,女7例.年龄（51.3±5.5）岁.体质指数（22.5 ±1.3） kg/m^2.肾结石并肾积水7例,输尿管结石并肾积水6例,肾盂输尿管连接部梗阻（UPJO）并肾积水2例.病变位于左侧10例,右侧5例.B组：男4例,女6例.年龄（48.4±8.3）岁,体质指数（21.5±1.7）kg/m^2.肾结石并肾积水4例,输尿管结石并肾积水5例,肾结核1例.病变位于左侧6例,右侧4例.均于全麻下手术.A组于脐下做一长约4 cm横切口,置入单孔多通道套件,放入30.10 mm腹腔镜,使用传统腹腔镜器械及预弯器械完成手术.B组在不延长切口的前提下于单孔多通道套件右侧置入10 mm套管,穿过肌层,该套管与单孔多通道套件于肌层及以下腹壁为两个独立的切口,术中更换器械更顺畅.比较两种术式的术中指标（手术时间、术中出血量、切口长度、是否增加套管、是否中转传统腹腔镜手术、是否输血）,术后指标（术后恢复进食时间、术后下床活动时间、留置引流管时间、术后住院时间、伤口总引流量、视觉模拟疼痛评分）及并发症情况.结果 A组15例,术中1例改为传统腹腔镜下单纯性肾切除术,2例增加辅助套管.平均手术时间（201.0 ±31.5）min,平均术中出血量（134.7±42.7）ml.B组10例手术均顺利完成.平均手术时间（170.0±19.6）min,平均术中出血量（174.4±43.9） ml.两组比较差异均有统计学意义（P＜0.05）.A组术后（3.2±0.7）d恢复进食,（3.8±0.8）d下床活动.术后（6.0±1.4）d拔除引流管,总引流量（135.2±21.7）ml.术后住院（7.6±1.4）d.视觉模拟疼痛评分（3.3±0.7）分.B组术后（3.5±0.8）d恢复进食,（3.1±1.1）d下床活动.术后（6.1±1.1）d拔除引流管,总引流量（126.2±31.0） ml.术后住院（6.7±1.1）d.视觉模拟疼痛评分（3.4±1.0）分.两组比较差异均无统计学意义（P＞0.05）.两组术中及术后均无严重并发症,术后仅脐下长约4 cm的手术瘢痕.结论 与经脐单孔腹腔镜下单纯性肾切除术比较,改良术式的手术时间缩短,操作难度明显降低,手术效果相同.改良术式是安全、可行的。

Objective To evaluate the safety and feasibility of applying modified transumbilical laparoendoscopic single-site surgery （LESS） nephrectomy in the treatment of kidney benign diseases.Methods From June 2012 to February 2014,15 patients（group A）with benign nonfunctioning kidney were performed transumbilical laparoendoscopic single-site simple nephrectomy by an experienced laparoscopic surgeon.From February 2014 to December 2014,10 patients （group B）with benign nonfunctioning kidney underwent modified transumbilical laparoendoscopic single-site simple nephrectomy by the same surgeon.Group A has 8 males and 7 females, with an average age of （51.3 ±-5.5） years and an average body mass index of（22.5 ± 1.3） kg/m^2.Of the 15 patients, 10 were left benign nonfunctioning kidney while 5 were right.The causes of nonfunctioning kidney included renal calculi （7 cases）, ureteral calculi （6 cases）, and ureteropelvic junction obstruction（2 cases）.Group B contains 4 males and 6 females,with an average age of （48.4 ±8.3）years and an average body mass index of（21.5 ± 1.7） kg/m^2.Of the 10 patieuts,6 were left side benign nonfunctioning kidney while 4 were right.The causes of nonfunctioning kidney included renal calculi（4 cases）, ureteral calculi （5 cases）, and renal tuberculosis （1 case）.An approximately 4 cm transverse incision was made below the umbilicus for single-port access in Group A.Operations were performed using 30＆#176;10 mm laparoscope with conventional and bending instruments.A 10 mm trocar next to the single-port access was added in group B without making a new skin incision, but with two incisions in the muscular layer.As two independent incisions, one is used for the single-port access, while the other is used for the 10mm trocar.This modified technique improves the procedure of the operation.A comparison was made between the two groups.Clinical indicators were collected before, during and after the operation, and complications of both groups were analyzed retrospectively.Results In group A, one case was converted to conventional laparoscopic nephrectomy, and 2 cases was added a trocar.Total operating time was significantly longer in group A than in group B [（201.0 ± 31.5） min vs.（170.0 ± 19.6） min,P =0.011）], but modified technique resulted in greater intra-operative blood loss [（134.7 ± 42.7） ml vs.（174.4 ± 43.9ml, P =0.034）].There were no significant differences in resuming diet, leaving bed, removing drainage, visual analogue pain scale and length of hospital stay between the two groups.There was no severe complications in both groups, but an approximately 4 centimeters scar.Conclusions Modified transumbilical laparoendoscopic single-site simple nephrectomy was safe and effective.It can effectively reduce the operating time and learning curve, with improved cosmetic result.