腹腔镜胰体尾切除手术入路及安全性

Surgical approach and safety of laparoscopic distal pancreatectomy

目的探讨腹腔镜胰体尾切除手术入路选择及安全性。方法回顾性分析2012年2月至2019年11月在佛山市第一人民医院行腹腔镜胰体尾切除的39例胰腺肿瘤患者临床资料。其中男10例,女29例;年龄19~75岁,中位年龄49岁。患者签署知情同意书,符合医学伦理学规定。采用五孔法腹腔镜胰体尾部切除术,选择顺行入路(Kimura法和Warshaw法)、胰尾优先入路和顺、逆行结合等手术入路。观察患者围手术期及并发症发生情况。结果37例患者成功实施腹腔镜胰体尾切除,2例因慢性胰腺炎粘连中转开腹手术。腹腔镜保留脾脏的胰体尾切除21例,其中Kimura法9例,Warshaw法4例,胰尾优先入路7例,顺逆行结合入路切除1例;腹腔镜联合脾脏切除的胰体尾切除16例。患者平均手术时间(272±91)min,术中出血量中位数200(50~1200)ml,术中输血1例,术后住院时间(10±4)d。术后生化瘘24例,B级胰瘘5例,无胰瘘8例。术后腹腔内出血2例,乳糜漏1例,急性下肢深静脉血栓1例。术后病理情况:浆液性囊腺瘤14例,黏液性囊腺瘤8例,胰腺神经内分泌肿瘤7例,实性假乳头状瘤3例,慢性胰腺炎2例,其他5例。结论腹腔镜胰体尾切除是一种安全的手术方法,术中根据肿瘤的大小、位置,与脾动、静脉血管的关系采取不同的手术入路,可减少术中出血,提高手术成功率和保脾成功率。

Objective To evaluate the selection and safety of surgical approach of laparoscopic distal pancreatectomy.Methods Clinical data of 39 patients with pancreatic tumors who underwent laparoscopic distal pancreatectomy in Foshan First People's Hospital from February 2012 to November 2019 were retrospectively analyzed.Among them,10 patients were male and 29 female,aged from 19 to 75 years,with a median age of 49 years.The informed consents of all patients were obtained and the local ethical committee approval was received.Five-port laparoscopic distal pancreatectomy was performed via antegrade approach(Kimura,Warshaw method),pancreatic caudal first approach or antegrade combined with retrograde approach.Perioperative conditions and incidence of complications of all patients were observed.Results 37 cases successfully underwent laparoscopic distal pancreatectomy,while 2 cases were converted to open surgery due to adhesion caused by chronic pancreatitis.Laparoscopic spleen-preserving distal pancreatectomy was performed in 21 cases,of whom 9 cases used Kimura method and 4 cases used Warshaw method,7 cases via pancreatic caudal first approach and 1 case via antegrade combined with retrograde approach.Laparoscopic distal pancreatectomy combined with splenectomy was performed in 16 cases.The average operation time was(272±91)min.The median intraoperative blood loss was 200(50-1200)ml.1 case received blood transfusion during the operation.The length of postoperative hospital stay was(10±4)d.Postoperatively,24 cases developed biochemical leakage,5 cases developed pancreatic fistula of grade B and 8 cases without pancreatic fistula.Postoperative intra-abdominal hemorrhage occurred in 2 cases,chylous leakage in 1 case and acute deep venous thrombosis of lower limb in 1 case.Postoperative pathological examination result showed 14 cases with serous cystadenoma,8 cases with mucinous cystadenoma,7 cases with pancreatic neuroendocrine tumors,3 cases with solid pseudopapillary tumors,2 cases with chronic pancreatitis and 5 cases with other complications.Conclusions Laparoscopic distal pancreatectomy is a safe surgery.Different surgical approach can be adopted according to the size,location of tumors and its relationship with splenic artery and vein,which helps to reduce the intraoperative blood loss and improve the success rate of operation and spleen-preserving rate.