弓状韧带与肾动脉关系的后腹腔镜肾切除解剖学研究

The anatomic relevance between the arcuate ligament and renal artery in retroperitoneal laparoscopic nephrectomy

目的探讨弓状韧带的解剖及其在后腹腔镜解剖性肾切除手术中作为肾动脉定位标志的临床意义。方法回顾性分析2008年1月－ 2014年7月行后腹腔镜解剖性肾切除术297例的病例资料。其中，男176例，女121例，年龄26～82岁，平均54.6岁。左侧174例，右侧123例。肾癌186例，肾盂癌74例，输尿管癌37例。术中采用“用多少，开多少，宁少勿多”的原则按需打开部分肾后间隙，显露腰大肌、腰方肌及膈肌等后腹腔解剖标志。识别内外侧弓状韧带，以内侧弓状韧带为导向，寻找并显露肾动脉。Hem-o-lok处理切断后，于其内下深面稍做游离，即可显露肾静脉，同法处理，总结后腹腔镜下内侧弓状韧带与肾动脉的解剖定位关系。结果后腹腔镜下可清晰识别三个肌性标志，即腰大肌、腰方肌及膈肌；及二个韧带标志，即外侧弓状韧带及内侧弓状韧带。内外弓状韧带在腔镜下呈现“海鸥”样外观，内侧弓状韧带水平向中线方向走行，正对肾动脉。以内侧弓状韧带为定位标志，297例手术快速寻找肾血管，明显缩短手术时间，同时也减少了因损伤肾血管出血而中转开放的几率。结论遵循“用多少，开多少，宁少勿多”的原则游离肾后间隙能依托肾周自身的悬吊固定结构显露肾血管，减少操作通道的数量；内侧弓状韧带是后腹腔镜上尿路手术中肾动脉的重要定位标志，以之为导引寻找肾动脉，能缩短手术时间。

ObjectiveTo study the anatomic characteristics of arcuate ligament and its clinical relevance as an anatomic landmark of the renal artery in retroperitoneal laparoscopic nephrectomy. Methods297 patients were underwent retroperitoneal laparoscopic operations in our institute from Jan 2008 to July 2014. These included 186 cases of renal cancer, 74 cases of renal pelvis cancer and 37 cases of ureteral carcinoma. There were 176 male and 121 female patients with the average age of 54.6 years （range from 26 to 82 years）. At first made a small incision in the lateral vertebral fascia, then dissociated the posterior pararenal space following the principle of “Dissociation according to need,Less rather than more”. The renal artery was found located at the psoas and the medial arcuate ligament of the diaphragm for anatomic landmark before the gap of the psoas.Then renal arteries were controlled by Hem-o-lok clips, the renal veins below the follow-up renal arteries were controlled in the same way. ResultsThe psoas major quadratus lumborum and diaphragm can be observed. The intersections of the diaphragm with psoas major and quadratus lumborum were bordered by the medial and lateral arcuate ligament, which looked like a seagull. The medial arcuate ligament extended towards the renal artery. This landmark enables us to locate renal artery quickly in all 297 cases. The operation time and risk of the vessel injury were reduced. ConclusionsThe dissociation of the posterior pararenal space following the principle of “Dissociation according to need,Less rather than more” can reduce numbers of Trocar; The medial arcuate ligament is a significant anatomic landmark for dissecting renal artery during retroperitoneal laparoscopic nephrectomy. Under the positioning of the medial arcuate ligament is an effective way to locate renal artery, can reduce the operation time of retroperitoneal laparoscopic nephrectomy.