“罪恶韧带”在腹腔镜胃癌手术中预防脾损伤的临床价值

Criminal fold priority separating reduces splenic injury in laparoscopic radical gastrectomy

目的 探讨＂罪恶韧带＂（独立于脾门外脾脏表面的纤维性附着带，可存在于脾脏上、中、下极）在腹腔镜胃癌根治术中预防脾损伤的临床价值。 方法 复习2011年10月至2017年3月广东省中医院胃肠外科的270例腹腔镜胃癌根治手术录像，总结＂罪恶韧带＂的解剖特点及其与脾脏撕裂的关系，并比较＂罪恶韧带＂预处理组与未预处理组脾脏撕裂发生情况。＂罪恶韧带＂预处理：在分离胃底和大弯上1/2对应的大网膜和脾脏区域时优先离断＂罪恶韧带＂。 结果 270例患者中220例（81.5%）存在＂罪恶韧带＂，可为1束至多束；脾下极出现率最高，为76.7%（207/270），脾上极出现率为9.6%（26/270），脾中间出现率为14.1%（38/270）。270例患者共出现医源性脾损伤30例（11.1%），其中预处理组脾损伤发生率分别为3.7%（2/54），低于未预处理组的13.0%（28/216），但差异尚未达到统计学意义（P= 0.07）。80%（24/30）的脾损伤为牵拉＂罪恶韧带＂所致，均发生在未预处理组；器械损伤占20%（6/30），其中预处理组2例，未预处理组4例。未预处理组2例患者因牵拉＂罪恶韧带＂发生Ⅱ度以上脾损伤，中转开腹行脾切除术；其余患者均为Ⅰ度脾损伤，经腹腔镜下电凝、黏合胶及压迫止血成功。结论 腹腔镜胃癌根治术中脾脏损伤主要是牵拉＂罪恶韧带＂所致，预处理＂罪恶韧带＂能安全、有效地减少术中脾损伤。

Objective To explore the value of criminal fold priority separating （CFPS） in reduction of iatrogenic splenic injury in laparoscopic radical gastrectomy. Methods Complete videos of 270 patients undergoing laparoscopic radical gastrectomy in Guangdong Provincial Hospital of Chinese Medicine were reviewed. Anatomic features of criminal fold （CF） were summarized. The relationship between CFPS and iatrogenic splenic injury was examined. CF was defined as the ligament between omentum and spleen. CFPS was defined as that CF was separated before the left half gastrocolic omentum was dissected. Splenic injury was further compared between CFPS group and non-CFPS group. Results CF occurred in 81.5% cases （220/270） , presenting one bunch or multiple bunches. CF appeared most commonly in the lower pole of spleen （76.7%, 207/270） , then in middle spleen （14.1%, 38/270） and upper pole （9.6%, 26/270） . CFPS was performed in 20% cases （54/270） and 80% cases （216/270） were non-CFPS. The incidence of iatrogenic splenic injury was 11.1% （30/270） , and this incidence of CFPS group was lower as compared to non-CFPS group （3.7%, 2/54 vs. 13.0%, 28/216） , but the difference was not significant （P= 0.07） . Of 30 patients with splenic injury, 24 （80%） were due to traction of CF and all were in non-CFPS group. Instrument injury occurred in 20% cases （6/30） and 2 were in CFPS group and 4 were in non-CFPS group. Most iatrogenic splenic injuries were successfully handled with electrocoagulation, adhesive and compression, except 2 patients underwent open splenectomy for serious splenic injury in non-CFPS group. Conclusion In laparoscopic surgery for gastric cancer, iatrogenic splenic injury mostly results from improper traction of CF and CFPS can reduce the incidence of iatrogenic splenic injury.