腹腔镜单层面法血管外支架植入术1例并文献复习

Transabdominal laparoscopic single-layer extravascular stent placement:a case report and literature review

目的探讨经腹腹腔镜单层面左肾静脉血管外支架植入术治疗胡桃夹综合征(NCS)的解剖特点及可行性。方法回顾性复习我院收治的1例NCS患者临床资料及手术录像。本例手术采用腹腔镜下,以Toldt平面为解剖标志进行游离,实施经腹途径左肾静脉血管外支架植入术。在游离过程中,对消化系统、泌尿生殖系统及Toldt筋膜的解剖关系进行观察,并查阅有关左肾、左肾上腺、左半结肠等脏器解剖性理论的书籍和文献,包括“层面外科”“膜-解剖”等理论。归纳总结消化、泌尿生殖系统与Toldt筋膜的解剖关系及术中注意事项。结果手术完成顺利,手术时间80 min,术中出血20 mL,无并发症发生,术后3 d血尿消失,随访1年无症状复发。术中可观察到清晰完整的Toldt筋膜平面,由左半消化系统附着于后腹膜上形成,然后整体卧伏于左半泌尿生殖系统之上。头侧界至膈腹膜,尾侧界至乙状结肠外侧系膜髂血管水平,外侧界止于Toldt线,内侧界为腹主动脉右侧缘。结论Toldt筋膜平面为一天然无血管层面,经腹腹腔镜单层面左肾静脉血管外支架植入术治疗NCS安全可靠,是一种可复制的手术入路,具备模式化潜能。

Objective To investigated the anatomic characteristics and feasibility of transabdominal laparoscopic single-layer extravascular stent placement for nutcracker syndrome(NCS).Methods The clinical data and surgical video of 1 NCS patient who underwent transabdominal laparoscopic extravascular stent placement in our hospital was retrospected.The anatomic landmarks was the Toldt fascia.During dissection,the anatomical relationships of the digestive system,the genitourinary system and the Toldt fascia were observed.And reviewed books and literatures on the anatomical theories of the left kidney,left adrenal gland,left colon and other organs,including theories such as“planes surgery”,“membrane anatomy”and so on.To summarized the anatomic relationship,characteristics and intraoperative precautions of the digestive system,the genitourinary system and the Toldt fascia.Results The operation was successful,the operation time was 80 minutes,the intraoperative bleeding was 20mL,no postoperative complications occurred,hematuria disappeared 3 days after surgery,no hematuria was observed during 1year follow-up.During surgery,a clear and complete Toldt fascia that was a no vascular structure can be observed.The Toldt fascia which was caused by the digestive system attached to the peritoneal separated the left digestive system from the left genitourinary system.The cranial border was the diaphragm,the caudal border was at the level of the intersection of sigmoid and left iliac artery,the left boundary was the white line of Toldt,the medial border was the right edge of the abdominal aorta.Conclusion The Toldt fascia is a natural no vascular plane,through which transabdominal laparoscopic extravascular stent placement surgery is safe and reliable.The single-larer operation method can be used and replicated for the treatment of nutcracker syndrome.