＂筋膜间隙优先＂保留左结肠动脉第253组淋巴结清扫在腹腔镜直肠癌根治术中应用价值

Application value of the clearance of No.253 lymph nodes with priority to fascial space and preserving left colic artery in laparoscopic radical proctectomy

目的探讨＂筋膜间隙优先＂保留左结肠动脉（LCA）的第253组淋巴结清扫方案在腹腔镜根治性直肠癌切除术的应用价值。 方法2015年8月至2016年8月期间，空军军医大学唐都医院胃肠外科对97例中低位直肠癌患者，应用＂筋膜间隙优先＂保留LCA的第253组淋巴结清扫方案实施腹腔镜根治性直肠癌切除术。简要步骤：常规中间入路，髂血管分叉处于＂膜桥＂处打开筋膜，进入Toldt间隙，借直肠上动脉为顶的＂帐篷式＂充分扩展Toldt间隙，下至骶骨岬下约2 cm处，上至胰腺下缘，向左至Toldt线，向右尽量扩展后，然后经头侧入路与尾侧中间入路分离的Toldt间隙会师并扩展至腹主动脉，完成筋膜间隙优先的步骤后，以肠系膜下动脉（IMA）根部为起始，显露LCA并清扫第253组淋巴结。该方案适用于无远处转移的直肠腺癌。 结果全组患者男52例，女45例，年龄（64.3 ± 5.5）岁，体质指数（22.4 ± 1.8）kg/m2。全组患者吻合后肠管、系膜均无张力，其中1例患者因LCA较细，在实施清扫时出血，予以夹闭，其余96例患者均成功实施第253组淋巴结清扫。第253组淋巴结清扫时间11~27（17.1 ± 5.3）min，第253组淋巴结清扫数量0~6（4 ± 2）枚，淋巴结阳性例数6例，第253组淋巴结区域边缘脏层、腹膜前面及背面完整者95例；总淋巴结数11~26（17.3 ± 5.3）枚。6例淋巴结阳性患者年龄为68~72岁，均在新辅助放化疗后6~8周施行全直肠系膜切除手术。全组患者手术时间89~189（125 ± 35）min，术中出血量10.5~38.6（22.4 ± 10.5）ml，术后肛门首次排气时间3.0~6.0（5.6 ± 2.1）d，术后拔除引流管时间3.0~5.0（4.5 ± 2.5）d；术后出现吻合口漏和少量出血各1例，均经保守治疗痊愈。全组无一例围手术期死亡。术后住院时间3.0~10.0（3.6 ± 2.6）d。 结论＂筋膜间隙优先＂保留LCA的第253组淋巴结清扫方案在腹腔镜直肠癌根治术中安全可行。

ObjectiveTo investigate the application value of the clearance of No.253 lymph nodes with priority to fascial space and preserving left colic artery （LCA） in patients undergoing laparoscopic radical proctectomy. MethodsFrom August 2015 to August 2016, 97 consecutive middle-low rectal cancer patients underwent laparoscopic radical proctectomy using the clearance of No.253 lymph nodes with priority to fascial space and preserving LCA at Department of General Surgery, Tangdu Hospital. Among 97 patients, 45 were females, 52 were males, mean age was （64.3±5.5） years and mean BMI was （22.4±1.8） kg/m2. Brief steps of this clearance： traditional medial approach was the commencement of the dissection at the membrane bridge line in front of iliac vascular bifurcation, then entering into the Toldt′s space; superior rectal artery served as the top of the tent and the Toldt′s space was extended as far as possible; blunt separation was developed caudally （reaching 2 cm below the sacral promontory） , cephalad （reaching the lower part of the pancreas） , left laterally （reaching Toldt′s line） , dextrally （reaching abdominal aorta） ; after giving priority to fascias space, from the root of inferior mesenteric artery, LCA was exposed and No.253 lymph nodes were dissected. This regimen was suitable for the rectal adenocarcinoma patients without distant metastasis. ResultsThere was no tension in the intestine and mesenteria after anastomosis in all the 97 patients. One patient received LCA ligation during the clearance, because of thinner LCA resulting in bleeding. The other 96 cases completed the clearance and operation successfully. The mean No.253 lymphadenectomy time was 11-27 （17.1±5.3） minutes. The mean number of harvested No.253 lymph node was 0-6 （4±2） . The No.253 lymph nodes of 6 patients were positive. No.253 regional mesentery was complete in 95 patients. The total harvested number of lymph node was 11-26 （17.3±5.3） . Six patients with positive lymph nodes aged from 68 to 72 years old and all of them underwent TME operation 6-8 weeks after neoadjuvant chemoradiotherapy. The mean operative time was 89-189 （125±35） minutes. The mean estimated blood loss was 10.5-38.6 （22.4±10.5） ml. The first exhaust time was 3.0-6.0 （5.6±2.1） days. The mean time to extracting the drainage tube was 3.0-5.0 （4.5±2.5） days. Anastomotic fistula appeared in 1 case and hemorrhage appeared in 1 case, and these 2 cases were cured by conservative treatment. No perioperative death occurred. The mean postoperative hospital stay was 3.0-10.0 （3.6±2.6） days. ConclusionThe clearance of No.253 lymph nodes with priority to fascial space and preserving LCA in laparoscopic radical proctectomy is safe and feasible.