预留缝线法在零缺血腹腔镜下肾部分切除术中的应用

Application of preplaced suture technique in zero ischemia laparoscopic partial nephrectomy(Report of 12 Cases)

目的:分析预留缝线法在零缺血腹腔镜下肾部分切除术(LPN)中的应用价值。方法:2015年1月~2016年2月我院共12例肾脏肿瘤患者运用预留缝线法在肾动脉无阻断条件下行LPN,其中男8例,女4例,平均年龄54.75(39~71)岁,肾脏肿瘤位于右侧7例、左侧5例,肿瘤直径1.95(1.5~2.5)cm。术前R.E.N.A.L评分为低危4.7(5~7)分,ASA评分为1.58(1~2)分。经后腹腔入路,采用预留缝线法行肾动脉无阻断下肾部分切除术:在肿瘤边缘1cm左右正常肾实质的位置预缝合一根1-0倒刺线,不收紧缝线,放置一旁备用。剪刀在预留缝线与瘤体之间分离肿瘤,配合使用吸引器边吸边切。若出血较多则对已预留缝线进行牵拉或收紧止血,出血仍无法控制时利用该缝线直接对已切除肿瘤部分暴露出的肾创面进行连续缝合修补至出血可控,重复至肿瘤完整切除;若出血量尚可,则直接完整切除肿瘤,后用预留的线缝进行肾实质的缝合修补。结果:12例患者均利用预留缝线方法完成肾动脉无阻断LPN术,手术全程无肾血供临时阻断,无中转开放手术病例。平均手术时间105.8(70~150)min、术中出血量85.8(40~150)ml,术中及术后均未输血,手术切缘阴性。术后病理提示11例患者为透明细胞癌,1例乳头状细胞癌。术后未见尿漏、切口感染、高热等并发症,平均引流管拔除时间3.5(3~5)d、住院时间5.3(4~7)d。随访6~12个月,肾功能未见明显异常,未见肿瘤复发。结论:预留缝线法能在不额外增加手术步骤情况下,确保无阻断LPN手术顺利完成,增加该术式的安全性和成功率,使患者避免热缺血所致肾功能损伤,从"零缺血"肾部分切除术获益。

Objective：To explore the application of preplaced suture technique in zero ischemia laparoscopic partial nephrectomy（LPN）and evaluate the value of clinical efficacy and prognosis.Method：Twelve patients with renal tumors underwent non-hilar clamping LPN between January 2015 to February 2016 in our hospital.There were eight males and four females with an average age of 54.75（range,39-71）years old.The renal tumors were located in the right side in seven cases and in the left side in five cases.The average tumor diameter was 1.95（range,1.5-2.5）cm.The average preoperative R.E.N.A.L score was 4.7（range,5-7）and ASA was 1.58（range,1-2）.Using preplaced suture technique in LPN：pre-suture a 1-0QUILL SRS suture in normal renal parenchyma adjacent to the tumor about 1cm,do not tighten the suture.Separate the tumor between the preplaced suture and tumor.When bleeding occurred,pull or tighten the suture to stop bleeding.If bleeding cannot control,then use the preplaced suture directly suture the exposed wound,repeated to complete the tumor resection.If the amount of bleeding is acceptable,we can suture the renal parenchyma using the preplaced suture after complete resection of the tumor.Result：LPN was successfully carried out in all cases.There was no temporary hilar clamping during the operation.The average operation time was 105.8（range,70-150）min.The average blood loss during operation was 85.8（range,40-150）ml.There was no blood transfusion during operation or after operation.Pathology showed 11 patients with renal cell carcinoma（RCC）and 1withpapillary carcinoma.There were no complications such as urinary leakage,incision infection or fever.The average hospitalization time was 5.3（range,4-7）days.Follow-up of 6-12 months,no obvious abnormal renal function or tumor recurrence was found.Conclusion：Zero ischemia LPN is expected to be completed successfully without additional surgical procedures by using the preplaced suture technique,thus we can maximize the clinical benefits for patients in renal function reservations by avoiding the kidney injury caused by warm ischemia.