经腹腔入路腹腔镜根治性肾切除术中两体一面解剖技术定位肾动脉的应用效果

The clinical application of two-complex and one-plane technique for renal artery location in transperitoneal laparoscopic radical nephrectomy

目的探讨经腹腔入路腹腔镜根治性肾切除术(LRN)中应用两体一面解剖技术定位肾动脉的临床效果。方法回顾性分析2016年1月至2019年12月实施经腹腔入路LRN并应用两体一面解剖技术定位肾动脉的206例肾肿瘤患者资料,其中71例来自开封市中心医院泌尿外科,135例来自郑州大学第一附属医院泌尿外科。男性126例,女性80例,中位年龄54岁(范围:35~82岁)。肿瘤位于左肾102例,右肾104例,肿瘤最大径(6.8±2.5)cm(范围:3.0~12.7 cm)。术中循生殖静脉定位肾静脉,以肾静脉复合体、肾下极复合体和腰大肌平面作为两体一面解剖标志定位肾动脉,记录两体一面解剖技术的实施情况、肾动脉解剖特征及其定位时间、血管相关并发症等。不同侧别手术结果的比较采用χ^(2)检验或t检验。结果手术均顺利完成,手术时间(54.4±13.6)min(范围:22~116 min),无中转开放,未发生肝、脾或肠管等副损伤。163例为单支肾动脉,43例为2~4支肾动脉,肾动脉主干之外共检出副肾动脉60支。右侧手术检出副肾动脉的比例为27.9%(29/104),高于左侧手术的13.7%(14/102)(χ^(2)=6.251,P=0.012)。肾动脉主干在肾静脉下、后方直接定位占80.1%(165/206),因位置偏高,在肾静脉复合体上缘开窗辅助定位占19.9%(41/206)。副肾动脉在肾静脉下、后方直接定位占76.7%(46/60),因位置偏高,辅助开窗定位占23.3%(14/60)。左侧手术肾动脉定位时间为(21.2±9.4)min(范围:11~43 min),右侧为(17.5±9.3)min(范围:9~32 min),两侧差异有统计学意义(t=2.840,P=0.005)。术中估计出血量(51.8±25.2)ml(范围:20~400 ml),发生4例血管损伤并发症,予以腔镜下处理,1例接受输血治疗。结论经腹腔入路腹腔镜LRN中以肾静脉复合体、肾下极复合体和腰大肌平面作为标志能够准确定位多种位置和解剖类型的肾动脉,肾动脉定位时间较短,血管损伤并发症发生率低。

Objective To examine the clinical application effects of two-complex and one-plane technique for the renal artery dissected location in transperitoneal laparoscopic radical nephrectomy(LRN).Methods Clinical data of patients diagnosed as renal tumor between January 2016 and December 2019 that treated with transperitoneal LRN and the two-complex and one-plane technique was performed to locate and dissect the renal arteries were analyzed retrospectively.A total of 206 qualified patients were enrolled,included 71 cases from Kaifeng Central Hospital and 135 cases from the First Affiliated Hospital of Zhengzhou University.There were 126 males and 80 females with median age of 54 years(range:35 to 82 years).Renal tumor lived at left kidney in 102 cases and at the right in 104 cases,with a maximum tumor diameter of(6.8±2.5)cm(range:3.0 to 12.7 cm).During the procession of transperitoneal LRN,The genital veins was followed to locate renal veins,soon the renal vein complex and renal lower pole complex and psoas major muscle plane that named as“two-complex and one-plane”anatomical markers were applied to the dissected location of renal arteries.The established application of two-complex and one-plane technique for renal artery location,and the anatomical features along with its locational time of renal artery,as well as vascular-related complications were recorded and analysed.Theχ2 test or t test was used to compare the results of different lateral operations.Results The surgical procedures were successful in all 206 patients.The operation time was(54.4±13.6)minutes(range:22 to 116 minutes),no injury to liver,spleen or intestine.Two-complex and one-plane technique was used to complete renal arteries location of 206 patients that accompanied with one or more arterial branch in the procession of transperitoneal LRN.Single renal artery branch was found in 163 cases,two or more renal artery branches were found in 43 cases,and 60 branches of accessory renal artery that in addition to the main trunks were detected in 14 cases(13.7%,14/102)on left-side and 29 cases(27.9%,29/104)on the right(χ^(2)=6.251,P=0.012).The main branch of renal artery that directly been located inferior or posterior to renal vein in 165 cases,and the other 41 cases that born with higher-position of main branch been located through an upper“window-opening”of renal veins complex.Of the 60 accessory renal artery,46 branch(76.6%,46/60)been located inferior or posterior to renal veins,and the other 14 branch with higher-position(23.3%,14/60)been located by a"window-opening"technique.The renal artery dissected location time was(21.2±9.4)minutes(range:11 to 43 minutes)in left-side and(17.5±9.3)minutes(range:9 to 32 minutes)in the right(t=2.840,P=0.005).The intraoprative bleeding was(51.8±25.2)ml(range:20 to 400 ml).There were 4 cases of vascular injury occured and treated with laporoscopy,only one need blood transfusion.Conclusions The anatomical markers of renal vein complex and renal lower pole complex and psoas major muscle plane that can apply to locate various anatomical position types of renal artery in transperitoneal LRN effectively.The exactly application of two-complex and one-plane technique that could shorten the operational time of renal artery location and reduce the complications of vascular injury.