3D腹腔镜腹部无切口经直肠标本取出治疗结肠慢传输性便秘可行性分析

Feasibility analysis on 3D laparoscopic surgery via transrectal extraction of specimens without abdominal incision in the treatment of slow transit constipation

目的探讨腹部无切口、经直肠拖出标本的3D腹腔镜辅助结肠次全切除术治疗结肠慢传输性便秘的安全性及可行性。方法2015年5月至2017年1月期间，上海同济大学附属东方医院胃肠肛肠外科从拟行3D腹腔镜手术的慢传输性便秘的患者中选择知情同意行腹部无切口经直肠拖出标本的8例入组“腹部无切口组”，其中女性6例，男性2例，手术采用3D腹腔镜手术行结肠次全切除术，升结肠起始部与直肠顺行端端吻合，标本经直肠断端由肛门完整取出：从行传统3D腹腔镜辅助结肠次全切除术的慢传输性便秘的患者中选择12例（性别、年龄和体质指数相近，与腹部无切口组施行手术的时间相差不超过12个月且同一主刀医师）入组“传统手术组”，女性9例，男性3例，其结肠按照传统方式经脐下正中5cm切口提出，处理近端结肠并在腔镜下完成端端吻合。分析比较腹部无切口和传统手术两组患者的围手术期情况（包括手术时间、术中出血量、术后排气时间和住院时间、围手术期并发症、术后疼痛评分以及附加镇痛处理情况）、术后1、3d的炎性指标（包括白细胞、降钙素原、白介素-6以及C反应蛋白）、术后腹腔感染情况、伤口愈合情况和术后1年的疗效以及对手术满意度的评价（患者主观百分制）。结果腹部无切口组手术时间、术中出血量、术后排气时间、术后并发症发生率和住院时间与传统手术组比较，差异无统计学意义（均P〉0．05）。腹部无切口组术后6h疼痛评分低于传统手术组（中位数3．0分比4．5分，U=23．0，P=0．042），术后第1天附加镇痛使用的比例少[1（1／8）比7（7／12），P=0．040]，差异均有统计学意义。术后第1天，腹部无切口组的白细胞水平低于传统手术组[（11．0±3．5）×10^9／L比（14．7±3．6）×10^9／L，t=-2．281，P=0．035]；术后第3天，两组C反应蛋白的比较差异无统计学意义[中位数78．1（0．1～154．0）mg／L比22．0（7．0～55．9）mg／L，U=33．0，P=0．247]．但有差异性趋势。术后两组降钙素原和白介素．6水平比较，差异无统计学意义（均P〉0．05）。所有患者均获随访，随访时间14～31个月。腹部无切口组患者疗效主观评分（90±9）分，传统手术组（94±6）分，症状改善均明显；两组差异无统计学意义（t=-1．099，P=0．286）。腹部无切口组远期未发生与腹腔感染相关并发症。结论腹部无切口、经直肠拖出标本的3D腹腔镜辅助结肠次全切除术治疗慢传输性便秘，可获得与传统腹腔镜辅助手术相同的近远期疗效，并且不会增加腹腔污染的可能。

Objective To investigate the safety and feasibility of 3D laparoscopic surgery via transrectal extraction of specimens without abdominal incision in the treatment of slow transit constipation （STC）. Methods From May 2015 to January 2017, 8 STC patients （6 females and 2 males） with informed consent were selected to receive subtotal colectomy with 3D laparoscopy as the no- incision incision group, in which the initial part of ascending colon and rectum were end-to-end anastomosed directly after extraction of the specimen through the rectum. Twelve STC patients （9 females and 3 males） undergoing traditional subtotal colectomy with 3D laparoscopy were selected as the traditional group by case matching method （gender, age, BMI, the difference of receiving operation time less than 12 months, same surgeon team）. Perioperative parameters （operation duration, intraoperative blood loss, exhausting time, postoperative hospital stay, complications, postoperative pain score and additional pain management）, inflammation index at postoperative day 1 and day 3 （leukocyte, procalcitonin, interleukin 6, C-reactive protein）, postoperative peritoneal infection, wound healing, short-term and long-term efficacy, patient satisfaction evaluation （subjective hundred-mark system） at postoperative one year were compared between two groups. Results There were no significant differences between two groups in operation duration, intraoperative blood loss, exhausting time, postoperative hospital stay and morbidity of complication （all P〉0.05）. Significantly lower pain scores at postoperative 6-hour （median 3.0 vs. 4.5, U=23.0, P=0.042）, lower ratio of additional analgesic at postoperative day 1 （1/8 vs. 7/12, P=O.040） were found in the no-incision group. Leukocyte level at postoperative day 1 was significantly lower in the no-incision group [ （11.0±3.5）× 10^9/L vs. （14.7±3.6） × 10^9/L, t=-2.281, P=0.035]. C-reactive protein concentration at postoperative day 3 was not significantly different between two groups but with different trend [median 78.1 （0.1 to 154.0） mg/L vs. 22.0 （7.0 to 55.9） mg/L, U=33.0, P=0.047]. There were no significant differences of interleukin-6 and procalcitonin between two groups （all P〉0.05）. All the patients had follow-up for 14-31 months. Subjective effectiveness score was 90±9 in the no-incision group and 94±6 in the traditional group without significant difference （t =-1.099, P=0.286）. No long-term complications associated with abdominal infection was observed in the no-incision group. Conclusion 3D laparoscopic subtotal colectomy via transrectal extraction of specimens without abdominal incision in the treatment of STC has similar short-term and long-term efficacies compared with traditional laparoscopic assisted surgery, and does not increase the probability of abdominal contamination.