腹腔镜肾部分切除术中肾动脉损伤的处理

Treatment of renal artery injury in laparoscopic partial nephrectomy

目的:探讨腹腔镜下肾部分切除术中肾动脉损伤的处理策略和操作方法。方法:回顾性分析2015年1月—2019年1月在海军军医大学附属东方肝胆外科医院泌尿外科经腰入路腹腔镜下肾部分切除术中出现肾动脉损伤的8例患者的临床资料。8例患者均在术中出现不同程度的肾动脉或其分支的损伤。通过正确判断损伤程度、增加Trocar操作位、纱布压迫、间断吸引、充分游离暴露、细致缝合的方法,在镜下完成对损伤血管的修复,并继续行肾部分切除术。结果:8例患者中,男6例,女2例,平均年龄(56.0±5.71)岁;肿瘤位于左肾3例,右肾5例;平均肿瘤直径3.5(2~5)cm;术前平均R.E.N.A.L.评分6(4~9)分。2例为肾动脉主干损伤,6例为肾动脉分支损伤。8例患者均在腹腔镜下完成对损伤肾动脉或其分支的缝合修复,并完成肾部分切除术,手术时间130~180 min,平均(158.13±20.52)min;总阻断时间26~38 min,平均(30.50±4.24)min;术中出血量平均(975±265.92)mL,术中平均输血(红细胞悬液)(550.00±297.61)mL;术后3个月复查患侧肾GFR 36.35~46.71 mL/min,平均(41.08±3.01)mL/min;5例患者术后病理为肾透明细胞癌,2例为嫌色细胞癌,1例乳头状肾细胞癌;手术切缘阴性。术后无低容量性休克、漏尿、切口感染等并发症,平均引流管拔除时间(6.75±0.46)d、术后卧床时间(3.63±0.52)d、术后住院天数13.25 d。结论:通过选择合理的处理策略和运用精细的操作动作,腹腔镜下肾部分切除术中发生的肾动脉损伤可以通过镜下缝合修复损伤的血管,保证患者生命安全的同时,避免中转开腹手术或根治性肾切除术。

Objective:To investigate the strategy and the management of the renal artery injury in laparoscopic partial nephrectomy.Methods:We made a retrospective analysis of 8 cases of renal artery injury occurred in laparoscopic partial nephrectomy in the Department of Urology of the 3rdAffiliated Hospital to the Naval Medical University during Jan.2015 to Jan.2019.The renal artery or its branches were injured in varying degrees.By correctly judging the degree of injury,increasing Trocar operation position,gauze compression,intermittent applying of the aspirator,full exposure and careful suture,the repair of injured vessels was completed under the laparoscope,then partial nephrectomy was able to be continued.Results:Among the 8 patients,6 were male and 2 were female,with an average age of(56.0±5.71)years.The tumors were located in the left kidney in 3 cases and in the right kidney in 5 cases.The average diameter of the tumors was 3.5(2-5)cm.The average R.E.N.A.L.score was 6(4-9)points.Injuries in two cases occurred in the main renal artery,while six cases occurred on the branches of renal artery.All the eight cases were successfully treated under laparoscope and the partial nephrectomy procedures were able to continue.The average operation time was(158.13±20.52)minutes(130-180 minutes).The mean total renal artery occlusion time was(30.50±4.24)minutes(26-38 minutes).The average amount of bleeding during the operation was(975.00±265.92)ml,and the average amount of blood transfusion(RBC suspension)during the operation was(550.00±297.61)mL.GFR of the affected kidney 3 months after the operation was(41.08±3.01)mL/min(36.35-46.71 mL/min).Five patients had renal clear cell carcinoma,2 patients had chromophobe cell carcinoma,and 1 patient had papillary renal cell carcinoma.All the surgical margins were negative.There were no complications such as low volume shock,leakage of urine or incision infection.The average time of drainage tube removal was(6.75±0.46)days,bed rest was(3.63±0.52)days and hospitalization was 13.25 days.Conclusion:By choosing a reasonable treatment strategy and using delicate manipulation,the renal artery injury in laparoscopic partial nephrectomy can be repaired by suturing the injured vessels under the laparoscope to ensure the safety of patient’s life,while avoiding conversion to open surgery or radical nephrectomy.