头侧中间入路的腹腔镜直肠癌根治术

Laparoscopic Total Mesorectal Excision of Rectal Cancer through Cephalo-Medial-to-Lateral approach

我们尝试采用头侧中间入路法以解决目前传统中间入路的一些不足。手术具体步骤包括:推开屈氏韧带处的空肠,切断该处附着的筋膜及韧带,将小肠肠袢完全推至右上腹部,显露屈氏韧带和左侧结肠系膜、腹主动脉及肠系膜下血管;从肠系膜下动脉(IMA)头侧的腹主动脉表面腹膜处打开进入左结肠后间隙,并顺势清扫IMA根部周围巴结;打开IMA尾侧的直乙结肠系膜并进入乙结肠后间隙,清扫IMA下方的周围淋巴结,并使乙结肠后间隙和左结肠后间隙贯通;显露IMA,肠系膜下静脉(IMV)和左结肠血管、乙结肠血管等相关血管,用血管夹夹闭离断相关血管根部,并可选择性的保留左结肠血管等。后续步骤同传统中间入路腹腔镜直肠癌根治术。

We developed a Cephalo-Medial-to-Lateral （ CML） approach to perform laparoscopic total mesorectal excision （ TME） to address the current technical hurdles in conventional medial approach .The CML approach involves entry to the left retrocolic space （ LRS） cranially to the root of the inferior mesenteric artery （ IMA） .To achieve this purpose , firstly to loose attachments on the jejunum , then the small bowel loops could be retracted upper right to reveal the ligament of Treitz , the left mesocolon , the aorta and the inferior mesenteric vessels .The LRS is entered from above the aorta and expanded downward to dissect the central lymph nodes .The rectosigmoid space caudally to the IMA is entered conventionally and expanded upward to join the LRS.Lymph nodes inferior to the IMA are dissected in this process .At this stage, the“T-shaped” space was exposed by the origin of IMA , the distal IMA and the left colic artery （ LCA ） are clearly identified and managed; the LCA can be divided individually without compromising lymph nodes dissection.The following pelvic dissection is similar to those of the conventional laparoscopic TME of rectal cancer through medial approach .