小切口开腹手术在直肠癌根治性切除手术中的应用

Curative resection with minilaparotomy approach in the treatment of rectal cancer

目的比较小切口开腹手术与腹腔镜技术在直肠癌根治性切除手术中的安全性和疗效。方法采用回顾性队列研究方法，收集2016年6月至2017年5月期间，上海长海医院肛肠外科行小切口或腹腔镜直肠癌根治术、并经术后病理证实为直肠癌的患者病历资料，排除术前急性完全性肠梗阻或肠穿孔、行Hartmann术和Miles术、小切口手术切口延长以及腹腔镜手术中转开腹的病例。共有216例直肠癌患者纳入本回顾性对照研究，其中143例行小切口直肠癌根治术（小切口手术组），73例行腹腔镜手术（腹腔镜手术组）。小切口手术组依据肿瘤位置，在脐与耻骨联合之间选取合适的切口位置，取下腹正中做一长度为7 cm的纵形切口；进腹后置入切口保护圈，常规清扫肠系膜下动脉根部淋巴结，根部离断、结扎肠系膜下血管；通过横向、纵向牵拉腹壁切口及S形拉钩的对抗牵拉，完成相应节段肠管及系膜的显露与游离，最后应用吻合器恢复肠道的连续性；对于腹膜反折以下的中低位直肠癌手术，术后常规关闭系膜裂孔及盆底腹膜。比较两组患者手术的安全性、术后恢复情况及术后并发症发生情况。结果全组男145例，女71例，中位年龄61（26～87）岁。TNM分期Ⅰ期61例，Ⅱ期62例，Ⅲ期85例，Ⅳ期8例。两组患者年龄、性别、体质指数、肿瘤位置、肿瘤TNM分期等基线资料的差异均无统计学意义（均P 〉 0.05）。两组患者均顺利完成手术。小切口手术组中位手术时间为164（80～296）min，短于腹腔镜组的230（90～665）min（Z = 4.410，P = 0.000）。与腹腔镜手术组相比，小切口手术组的术中耗材费用[1.1（0.7～2.2）万元比2.3（1.2～4.7）万元，Z = 11.759，P = 0.000]及住院总费用[4.4（2.2～14.6）万元比5.7（4.5～12.6）万元，Z = 9.637，P = 0.000]均较低。两组术中出血量、肠系膜淋巴结清扫数量、下切缘距离及环周切缘阳性率的差异均无统计学意义（均P 〉 0.05）。小切口手术组并发症发生率为7.0%（10/143），腹腔镜手术组并发症发生率为9.6%（7/73），差异无统计学意义（χ^2 = 0.449，P =0.503）。两组各有2例患者术后30 d再入院，小切口手术组再入院原因分别为肠梗阻和低钠血症；腹腔镜组则分别为肠梗阻和盆腔感染。小切口手术组出现1例围手术期死亡病例，死亡原因为术后急性肺动脉栓塞引起的脑死亡。结论小切口开腹术应用于直肠癌的根治性切除安全、可行。相对于腹腔镜手术，小切口直肠癌根治术在取得同样微创效果的同时，更加节省手术时间及手术费用。

ObjectiveTo compare the surgical safety and short-term efficacy of minilaparotomy and laparoscopic approach for curative resection of rectal cancer.MethodsThe retrospective cohort study was adopted. A review of patients scheduled to undergo a curative resection of rectal cancer via minilaparotomy or laparoscopic approach at Department of Colorectal Surgery of Changhai Hospital from June 2016 to May 2017 was carried out. All the patients were confirmed as rectal cancer by postoperative pathology. The following patients were excluded from the study： patients who had acute complete obstruction or perforation; patients underwent Miles or Hartmann procedure; patients who required an elongation of the skin incision in minilaparotomy or a conversion from laparoscopic to open surgery. Finally, 216 patients were enrolled in this study, of whom 143 were performed with minilaparotomy approach （minilaparotomy group） and 73 with laparoscopic approach （laparoscopic group） for curative resection of rectal cancer. For the minilaparotomy technique, a 7 cm longitudinal midline incision was made between the pubic symphysis and umbilicus; a wound retractor was applied to the edge of the wound; lymph node dissection around the inferior mesenteric and artery high ligation of inferior mesenteric artery were performed; by moving the minilaparotomy wound laterally and caudad or cephalad with the S-shaped hook, cautious mobilization of the relevant segment of the bowel loop was performed; bowel anastomosis was achieved by using the double-stapled technique; the gap of the pelvic floor peritoneum and mesentery were routinely closed by the absorbable surgical suture in cases with middle and low position rectal cancer. The surgical safety, the condition of resuming and the morbidity of postoperative complication were compared between the two groups.ResultsThere were 145 men and 71 women. Age ranged from 26 to 87 years, with of mean age of 61 years. According to the TNM stage grouping, there were 61 patients with stage Ⅰ, 62 with stage Ⅱ, 85 with stage Ⅲ, and 8 with stage Ⅳ disease, respectively. These two groups did not differ significantly in terms of age, sex, body mass index, site of tumor, TNM stage （all P 〉 0.05） . All the patients completed the operation successfully. The median operation time of minilaparotomy group was significantly shorter than that of laparoscopic group [164 （80-296） minutes vs. 230 （90-665） minutes, Z = 4.410, P = 0.000]. The intraoperative medical consumable expense [11 000 （7 000-22 000） yuan vs. 23 000 （12 000-47 000） yuan, Z = 11.759, P =0.000] and the total hospitalization expense [44 000 （22 000-146 000） yuan vs. 57 000 （45 000-126 000） yuan, Z = 9.637, P =0.000] were significantly lower in the minilaparotomy group. There were no significant differences between the two groups in terms of operative blood loss, number of harvested lymph nodes, distance of distal resection margin, positive rate of circumferential resection margin （all P 〉 0.05） . The rate of postoperative complication in minilaparotomy group was 7.0% （10/143） and in laparoscopic group was 9.6% （7/73） without significant difference （χ^2 = 0.449, P = 0.503） . There were 2 patients in each group who required readmission to the hospital within postoperative 30 days. The cause of readmission was ileus or acute hyponatremia in minilaparotomy group, and ileus or pevic infection in laparoscopic group. One patient died of brain death caused by acute pulmonary embolism during the perioperative period in minilaparotomy group.ConclusionsThe minilaparotomy approach for curative resection of rectal cancer is safe and feasible. As compared with laparoscopic approach, it is advantageous to achieve minimal invasiveness and early recovery, but much cheaper and less time consuming.