微创肿大淋巴结切除手术技巧

Minimally invasive surgical technique for excising hypertrophic lymph nodes

目的盆腹腔肿大淋巴结常侵犯大血管、神经、输尿管等,切除过程中肿大淋巴结可能破碎,瘤液外渗,且可能出现损伤大血管等情况导致切除失败,以1例局部晚期宫颈癌患者为例,探讨无夹持整块切除肿大淋巴结的微创手术技巧。方法回顾性分析2021年1月在重庆大学附属肿瘤医院妇科肿瘤中心就诊的1例局部晚期宫颈鳞癌ⅢC1r,接受腹主动脉旁淋巴结切除分期手术,术中同时除盆腔肿大淋巴结,术后同步放化疗患者的临床资料。结果患者接受da Vinei Xi机器人微创手术,术中秉承“easy first”原则由简至难逐层推进,根据“隧道原理”钝锐结合稳步分离,保护血管、“保护”淋巴结,间隙出现“热兵器”,紧密贴合“冷兵器”整块切除盆腔巨块淋巴结和腹主动脉旁淋巴结。术中出血少、无损伤,手术病理分期为宫颈鳞癌Ⅲ C2p,术后13 d开始同步放化疗,并在60d内放疗结束,副反应为Ⅰ级胃肠道反应和中性粒细胞减少。治疗后评估达CR,随访两年无异常。结论采用无夹持整块切除方法切除局部晚期宫颈癌盆腹腔肿大淋巴结是安全可行的,可有效避免淋巴结破损导致的肿瘤外溢,减轻瘤负荷,不延长放疗开始的时间。

Objective Enlarged pelvic and abdominal lymph nodes often invade major blood vessels,nerves,and ureters.Resection of these nodes may result in surgical failure due to rupture,tumor fluid leakage or damage to large blood vessels.This study presents a case of locally advanced cervical carcinoma as an example to explore the minimally invasive surgical technique of non-clamping whole-block excision.Methods A retrospective analysis was conducted on clinical data from a patient with stage ⅢClr locally advanced squamous cervical cancer who underwent staged surgery for para-abdominal aortic lymph node dissection and simultaneous removal of pelvic mega-lymph nodes at the Gynecological Oncology Center in Chongqing University Cancer Hospital in Jan.2021.Results The da Vinci Xi robot was used for minimally invasive surgery following the principle of sequential layer-by-layer advancement from simple to difficult(the“easy first”principle).The procedure employed the“tunnel principle”to carefully separate lymph nodes using a combination of blunt and sharp techniques while ensuring protection of blood vessels and preserving lymph node integrity.Advanced surgical tools were strategically used for precise removal of pelvic giant lymph nodes and para-aortic lymph nodes as a single unit.Intraoperative bleeding was minimal without any complications.Surgical pathology revealed stage ⅢC2p cervical squamous carcinoma.Concurrent chemoradiotherapy started 13 days after surgery and was successfully completed within 60 days with mild grade Ⅰ gastrointestinal reaction and neutropenia observed as treatment side effects.After treatment,complete response(CR)was achieved with no recurrence during the two-year follow-up period.Conclusion The non-clamping whole-block excision technique provides a secure and feasible approach for the removal of locally advanced cervical cancer with pelvic and abdominal lymph node enlargement.This method effectively mitigates tumor dissemination resulting from lymph node damage,reduces tumor burden,and does not impact the timing of radiotherapy initiation.