基于膜解剖的胃后间隙入路在全腹腔镜近端胃切除双通道吻合术中的应用

Application of Mesenteric Anatomy-based Surgical Access to the Posterior Gastric Space in Total Laparoscopic Proximal Gastrectomy Followed by Double-tract Reconstruction

目的探讨“基于膜解剖的胃后间隙入路”(我们称之为“欢乐间隙”)联合食管空肠自牵引后离断吻合技术(self-pulling and latter transection,SPLT)在全腹腔镜近端胃切除、双通道吻合术中的应用价值。方法2019年9月~2021年9月,对15例T1~2N0M0食管胃结合部肿瘤行3D全腹腔镜下近端胃切除、双通道吻合术。“欢乐间隙”为我们基于“膜解剖”理论提出的位于腹腔干左侧、胰腺上后缘的Gerota筋膜与胃背系膜之间的融合筋膜间隙,手术进入此间隙可快速完成胃后部分的分离并完成手术,术者感到愉悦,故称为“欢乐间隙”。使用SPLT技术行食管-空肠吻合。结果15例均顺利完成全腹腔镜手术。手术时间(237.5±55.3)min,术中出血量(84.7±28.3)ml,术后排气时间(2.1±0.4)d,术后进流质饮食时间(2.9±1.1)d,术后引流时间(6.4±0.9)d,总住院时间(15.1±2.1)d。术后病理腺癌11例,高级别上皮内瘤变4例,切缘均为阴性。术后肺部感染2例。随访1年,均未出现反流性食管炎及肿瘤复发,各营养指标变化差异无显著性(P>0.05)。结论“欢乐间隙”入路联合SPLT技术在全腹腔镜近端胃切除、双通道吻合术中安全可行。

Objective To investigate the value of the“mesenteric anatomy-based surgical access to the posterior gastric space”(the author’s team calls it the“enjoyable space”)combined with the self-pulling and latter transection(SPLT)technique in total laparoscopic proximal gastrectomy followed by double-tract reconstruction.Methods From September 2019 to September 2021,15 cases of T1-2N0M0 esophagogastric junction carcinoma were operated with 3D total laparoscopic proximal gastrectomy with double-tract reconstruction.The“enjoyable space”was a fused fascial space between the Gerota’s fascia and the dorsal gastric mesogastrium on the left side of the abdominal trunk and the superior posterior margin of the pancreas,which was proposed by our team based on the theory of“mesenteric anatomy”.Performance into this space could complete the separation of the posterior part of the stomach quickly and complete the surgery quickly,making the operator feel happy,hence it was called the“enjoyable space”.The SPLT technique was used to perform esophago-jejunostomy.Results The total laparoscopic surgery were successfully completed in all the 15 cases.The operative time was(237.5±55.3)min,the intraoperative bleeding was(84.7±28.3)ml,the postoperative time to exhaustion was(2.1±0.4)d,the postoperative time to liquid diet was(2.9±1.1)d,the postoperative drainage time was(6.4±0.9)d,and the total hospital stay was(15.1±2.1)d.The postoperative pathology suggested adenocarcinoma in 11 patients and high-grade intraepithelial neoplasia in 4 patients.The cut margin was negative in all the cases.Two patients had postoperative complications of pulmonary infection.Follow-ups for 1 year showed no reflux esophagitis or tumor recurrence,and no significant differences in changes of nutritional indexes(P>0.05).Conclusion The“enjoyable space”approach combined with the SPLT technique is safe and feasible in total laparoscopic proximal gastrectomy followed by double-tract reconstruction.