CT三维重建导航下行中间入路“六步法”腹腔镜右半结肠切除术近期疗效研究

Short-term clinical efficacy of“six-step”procedure for laparoscopic right hemicolectomy with medial approach under the navigation of computed tomography three-dimensional reconstruction

目的探讨CT三维重建导航下行中间入路“六步法”腹腔镜右半结肠切除术的短期临床疗效。方法前瞻性纳入2019年1月至2022年9月中国医科大学附属盛京医院结直肠肿瘤外科收治的151例右半结肠癌病人,择期行中间入路“六步法”腹腔镜右半结肠切除术。术前全部完成CT三维重建,辨识肠系膜上动脉(SMA)、肠系膜上静脉(SMV)及各分支与属支解剖,以指导术中血管精细解剖。观察指标包括:血管解剖辨识情况、术中情况、标本与病理学检查情况、术后短期结果。结果(1)术中血管解剖辨识情况:SMV存在数量变异,包括单支型SMV(94.7%)与双支型SMV(5.3%)。单支型SMV相对于SMA空间关系包括右位型(95.1%)与交叉型(4.9%)。右结肠动脉(RCA)出现率37.7%。回结肠动脉(ICA)走行于SMV前位与后位分别占45.0%与55.0%。ICA相对于回结肠静脉(ICV)的空间关系分为6种:正前位(10.6%)、前上位(20.5%)、前下位(13.9%)、正后位(12.6%)、后上位(31.1%)、后下位(11.3%)。通过术中验证,术前CT三维重建可以准确识别肠系膜上血管主干变异、RCA出现情况以及回结肠血管空间关系,二者在判断Henle干分型上具有较好一致性。(2)术中结果:手术时间(144.4±26.5)min。手术中位出血30mL(10~150 mL)。术中血管性出血5例(3.3%),均为超声刀使用不当所致的静脉损伤。(3)标本与病理学检查结果:远端切缘长度为(15.7±4.2)cm,术中清扫淋巴结数目中位数为25枚(10~53枚),清扫淋巴结数目≥12枚为147例(97.4%),第3站淋巴结检出数目中位数为6枚(3~12枚)。(4)术后短期结果:术后首次恢复排气中位时间3.5 d(2.0~5.0 d),首次恢复排便中位时间4.5 d(2.0~10.0 d)。按照Clavien-Dindo并发症分级系统,术后Ⅰ级并发症中切口并发症4例、术后低钾血症2例;Ⅱ级并发症中,1例不完全性肠梗阻、3例淋巴漏、1例吻合口出血、8例术后感染相关性事件;Ⅲ级并发症中,1例术后出现吻合口漏,经介入治疗恢复。1例因术后粘连性完全性肠梗阻,二次手术治疗。结论利用术前CT三维重建可以较准确预知肠系膜血管解剖,可能有助于降低术中出血风险。CT三维重建导航下中间入路“六步法”腹腔镜右半结肠切除术短期疗效满意。

Objective To investigate the short-term clinical efficacy of laparoscopic right hemicolectomy with a medial approach using a"six-step"procedure under the navigation of three-dimensional(3D)reconstruction of computed tomography(CT).Methods A total of 151 patients with right colon cancer underwent laparoscopic right hemicolectomy with"six-step"procedure in the Department of Colorectal Tumor Surgery of the Shengjing Hospital of China Medical University from January 2019 to September 2022 were enrolled in this prospective study.The superior mesenteric artery(SMA),superior mesenteric vein(SMV),and their corresponding branches were identified before surgery under 3D reconstruction imaging,so as to guide the accurate dissection during the operation.The observation indicators included:Vascular anatomy conditions;Intraoperative situations;Postoperative specimens and pathological examinations;Short-term postoperative results.Results(1)Intraoperative vascular anatomy conditions:according to the number of SMV,the variation of the SMV can be divided into single-type(94.7%)and double-type(5.3%).We identified two spatial locations of the single SMV relative to the SMA—1.right-sided-type(95.1%)and crossovertype(4.9%).The incidence of right colonic artery(RCA)was 37.7%.The ileocolic artery(ICA)ran on the ventral and dorsal side of SMV accounted for 45.0%and 55.0%,respectively.We identified six spatial positions of the ICA relative to the ileocolic vein(ICV):positive anterior position(10.6%),anterior upper position(20.5%),anterior lower position(13.9%),positive posterior position(12.6%),posterior upper position(31.1%),and posterior lower position(11.3%).The variations of SMV and SMA,the occurrence of RCA,and the spatial structure of the ileocolic vessels could be identified accurately under the images of 3D reconstruction.There was a good level of agreement of Henle type for comparison of the findings on3D reconstruction with those at the surgery.(2)Intraoperativesituations:the operation time was 144.4±26.5 minutes,and the intraoperative blood loss was 30ml(range,10-150ml).The venous injury occured in 5 cases(3.3%)caused by improper use of the ultrasonic knife.(3)Postoperative specimens and pathological examinations:the length of the distal resection margin was 15.7±4.2cm,the number of lymph nodes dissected was 25(range,10-53),and 147(97.4%)patients had no less than 12 lymph nodes.The number of central lymph nodes detected was 6(range,3-12).(4)Short-term postoperative results:the time to first flatus and the first defecation was 3.5 d(range,2.0-5.0 d)and 4.5 d(range,2.0-10.0 d),respectively.According to the Clavien-Dindo complication grading system,4 cases with incision complications and 2 cases with hypokalemia in grade I.Of gradeⅡcomplications,1 case with intestinal obstruction,3 cases with lymphatic leakage,1 case with anastomotic hemorrhage,and 8 cases with infection-related events.Of gradeⅢcomplications,1 case with anastomotic leakage,which was received interventional treatment.1 case was treated with a second operation due to adhesive and complete intestinal obstruction.Conclusion Preoperative 3D reconstruction imaging is beneficial for identifying the vascular anatomy and the surgical safety may be increased during operation.The laparoscopic right hemicolectomy with a medial approach using a“six-step”procedure is safe and feasible.