3D膜解剖理念在腹腔镜腹膜外入路根治性膀胱切除术中的初步应用

Concept of 3D membrane anatomy in extraperitoneal laparoscopic radical cystectomy:preliminary application

目的探讨基于3D膜解剖理念的腹腔镜腹膜外入路根治性膀胱切除术的临床可行性。方法回顾性分析2020年10月至2021年6月于安徽医科大学第二附属医院行3D腹腔镜腹膜外入路根治性膀胱切除+回肠原位新膀胱术的10例膀胱癌患者的临床资料。均为男性,中位年龄67(53~79)岁;美国麻醉医师协会评分1~2分8例,3分2例;有吸烟史6例;合并高血压病4例,糖尿病2例,心脏病1例;均无腹盆部手术史。术中基于3D膜解剖理念对盆腔内重要筋膜进行识别定位,即由膀胱前筋膜平面分离到达膀胱侧间隙,并与Retzius间隙、Bogros间隙汇合,在膀胱前筋膜、膀胱腹下筋膜和尿生殖筋膜包绕形成的层面内解剖以完成膀胱切除过程。结果所有患者手术均顺利完成,无中转经腹腔途径或开放手术;术中无腹膜损伤。手术时间中位值276(237~325)min,术中失血量中位值160(50~280)ml;术后肠道功能恢复时间中位值1.8(1~3)d,术后下床活动时间中位值1.3(1~2)d,术后住院时间中位值9(5~12)d。所有患者淋巴结清扫数量中位值10(6~20)枚,淋巴结阳性3例,10例切缘均为阴性;术后病理分期T_(2b)N_(0)期5例,T_(2b)N_(1)期2例,T_(3a)N_(0)期2例,T_(3b)N_(1)期1例。中位随访6(2~10)个月,所有患者均无严重并发症。结论在腹膜外入路根治性膀胱切除术中运用3D膜解剖理念识别定位关键的筋膜结构与层面切实可行,术中解剖清晰,可降低手术难度;手术相关并发症少,术后恢复较快。

Objective To explore the clinical feasibility of extra-peritoneal laparoscopic radical cystectomy based on the concept of 3D membrane anatomy.Methods The clinical data of 10 male patients with bladder cancer who underwent 3D extra-peritoneal laparoscopic radical cvstectomv+ileal-orthotopic-neohladder surgery from October 2020 to June 2021 were retrospectively analyzed.The median age was 67 years.The ASA score was 1-2 in 8 cases and 3 in 2 cases.There were 4 cases of hypertension,2 cases of(lial)etes,I case of heart disease,no case of abdominal surger\histoiy.During the operalion,tlie concept of 3D membrane anatomy was used to identify the important fascia in the pelvic cavity and to find the key layers and structures in the pelvic cavity.It was separated from the prevesical fascia to the laterovesical space,and confluenced with Hetzius spare and Bogros spare.It was dissected in the layer surrounded by the prevesical fascia,the vesicohypogastric fascia,and the urogenital fascia to complete the process of cystectoniv.Results Tlie operations of 10 patients were completed successfully and there was no conversion to open operation.The median operation time was 276(237-325)minutes,and the median hlood loss was 160(50-280)ml.The postoperative bowel recovery median time was 1.8(1-3)tlavs,and the patients were out of bed about 1.3(1-2)days.The median postoperative hospital stay was 9(5-12)days.The numher of median lymph node dissection in all patients was 10(6-20).Positive lymph nodes was found in 3 cases.Positive margin was fourul in no case.Postoperative tumor pathological stages were T_(2),stage in 7 cases,T_(3)stage in 3 cases.During the follow-up,all patients had no obvious complications.Conclusions It is feasible to apply the concepl of 3D membrane analomy to identify and locate the key fascia stmetures and levels in extra-peritoneal laparoscopic radical cystectomy.Tie operative c-oniplications were less and the postoperative recoveiy was faster.The anatomy is clear during the operation,which lias good safety and reduces the difficulty of tie operation.