普通腹腔镜器械单孔后腹腔镜输尿管切开取石术的临床应用(附15例报告)

Retroperitoneal laparoendoscopic single-site ureterolithotomy using conventional laparoscopic instruments:A report of 15 cases

目的介绍应用普通腹腔镜器械行单孔后腹腔镜输尿管切开取石术的手术方法及评价其临床可行性和安全性。方法 2012年5月至2015年12月,使用普通腹腔镜器械对15例输尿管上段结石患者行单孔后腹腔输尿管切开取石术。患者健侧卧位,取髂嵴上方2~4cm处约3cm横切口,Veress针穿刺入腹膜后间隙,CO_2气腹,10mm Trocar于切口中点下缘处直接穿刺置入腹膜后间隙,经Trocar置入自制气囊并充气扩张腹膜后腔,置入10mm硬性30°腹腔镜,监视下于切口两端上缘分别穿刺置入5mm Trocar。按照普通腹腔镜方法行输尿管切开取石术。结果 14例单孔腹腔镜手术成功,1例因术中漏气明显,于腋后线增加1个5mm Trocar。手术时间45~78min,平均61.5min;术中估计出血量5~20mL,平均7.4mL。其中14例患者术后住院时间7~8(平均7.7)d,术后第2~4天拔除引流管(平均2.7)d,术后1~3个月拔除双J管,术中无并发症发生;另1例患者术后第2天出血,采取保守治疗,第6天出现漏尿,拔除双J管,术后第28天拔除导尿管,术后第30天拔除切口皮管,术后住院时间31d。术后随访3~30个月,平均10.6月,复查CT均无结石复发,肾积水消失或减轻。结论初步结果显示普通腹腔镜器械单孔后腹腔镜输尿管切开取石术安全、可行,具有良好的微创及美容效果,短期疗效确切,但其长期疗效尚需长期随访及大样本、随机对照研究证实。

Objective To introduce our technique of retroperitoneal laparoendoscopic single-site （LESS） ureterolithotomy using conventional laparoscopie instruments in the treatment of upper ureteral calculi. Methods During May 2012 and Dec. 2015, 15 patients underwent retroperitoneal LESS ureterolithotomy conducted by the same surgical team. The patients were placed in the lateral decubitus position, with the side ipsilateral to the stones. A 3.0 cm incision was made 2-- 4 cm above the il- iac crest. A Veress needle was inserted into the retroperitoneal space through the incision. Then a 10 mm Trocar was placed in the midpoint of the incision. A homemade glove balloon was placed in the retroperitoneal space to inflate it. A rigid 10 mm 30° conventional laparoscope was inserted. A 5 mm Trocar was punctured on either side of the incision, and conventional laparo- scopic instruments were used for surgery. The operation procedure was similar to that of the conventional retroperitoneal lapa- roscopic ureterolithotomy. Results Of all 15 operations, 14 were successful, and 1 case needed a 5 mm assistant Trocar due to leakage of carbon dioxide. The operation time was 45--78 min （mean 61.5）, and the estimated blood loss was 5--20 mL （mean 7.4）. Of the 14 successful cases, no intraoperative and postoperative complications were observed, the postoperative hospital stay was 7--8 days （mean 7.7）, the drainage tube was removed 2--4 days after operation （mean 2.7）, and the stent was removed 1--3 months after operation. For the 1 case, bleeding occurred 2 days after operation, urine leakage occurred 6 days after operation, and then the stent was removed. The urethral catheter and drainage tube were removed 28 and 30 days after operation, respectively. The patient was discharged 31 days after operation. During the follow-up of 10 30 months （mean 10.6）, no recurrence was observed. Oonclusions The LESS ureterolithotomy using conventional laparoscopic instru- ments is safe and feasible, with favorable surgical and cosmetic outcomes. However, long-term follow-up and large-scale ran- domized controlled studies are needed to verify the efficacy of this technique.