腹腔镜右半结肠切除术腹腔内吻合技术改良对短期结局影响研究

The effects of modified laparoscopic right hemicolectomy on the short-term outcomes of intracorporeal anastomosis

目的探讨腹腔镜右半结肠切除术病人采用不同取标本位置对腹腔内和腹腔外吻合术后短期结局的影响。方法回顾性分析2016年1月至2023年6月北京协和医院基本外科结直肠专业组收治的728例行右半结肠切除术病人的临床资料,其中行腹腔外吻合474例,腹腔内吻合254例。2021年8月前,采用延长左上腹主操作孔取标本,行腹腔外吻合359例,腹腔内吻合154例;2021年8月后,采用延长中下腹观察孔取标本,行腹腔外吻合115例,腹腔内吻合100例。采用倾向性评分逆概率加权法(IPTW)对同期组间基线特征进行平衡,比较标本取出部位改变前后不同吻合方式病人术后短期结局情况。结果(1)采用延长左上腹主操作孔取标本期间,与腹腔外吻合组比较,腹腔内吻合组病人手术时间延长,总并发症、腹腔感染、腹腔感染(不含吻合口漏)、手术切口感染发生率均增高,差异有统计学意义(P<0.05)。(2)采用延长中下腹观察孔取标本期间,与腹腔外吻合组比较,腹腔内吻合组病人清扫淋巴结数目增多、手术时间延长、术后住院时间缩短,差异有统计学意义(P<0.05);但两组总并发症、Clavien-DindoⅢ~Ⅳ级并发症、腹腔感染(含或不含吻合口漏)、吻合口漏、手术切口感染发生率差异无统计学意义(P>0.05)。(3)在腹腔内吻合病人中,与取标本位置改良前相比,改良后手术时间缩短,术中出血减少,术后住院时间缩短,总并发症和手术切口感染发生率均降低,差异有统计学意义(P<0.05)。结论腹腔镜右半结肠切除术取标本位置由左上腹主操作孔改为中下腹观察孔,腹腔内吻合病人手术切口感染发生率显著下降,故应避免经主操作孔取标本,以降低手术部位感染风险。

To investigate the effects of different specimen extraction locations on the short-term outcomes of patients who underwent intracorporeal or extracorporeal anastomosis in laparoscopic right hemicolectomy.Methods A retrospective analysis was conducted based on the clinical data of 728 patients who underwent laparoscopic right hemicolectomy at the Division of Colorectal Surgery,Department of General Surgery,Peking Union Medical College Hospital between January 2016 and June 2023,of whom 474 patients underwent extracorporeal anastomosis and 254 patients underwent intracorporeal anastomosis.Before August 2021,the specimen was removed through a protected incision extended from main operation trocar on the upper left abdomen,among which there were 359 cases of extracorporeal anastomosis and 154 cases of intracorporeal anastomosis.After August 2021,the specimen was removed through a protected incision extended from observation Trocar on the mid-lower abdomen,among which there were 115 cases of extracorporeal anastomosis and 100 cases of intracorporeal anastomosis.The propensity score inverse probability weighting method(IPTW)was used to balance the baseline characteristics between groups.When the specimen was extracted from different sites,the short-term outcomes of intracorporeal and extracorporeal anastomosis were compared.Results(1)When the upper left abdomen was chosen as the specimen extraction site,patients from intracorporeal anastomosis group had a prolonged operation time and an increased incidence of overall complications,abdominal infection,abdominal infection(excluding anastomotic leakage),and wound infection were observed than patients from extracorporeal anastomosis group,with a significant difference(P<0.05).(2)When the mid-lower abdomen was chosen as the specimen extraction site,patients from intracorporeal anastomosis group had more dissected lymph nodes,a longer operation time,and a shorter postoperative hospital stay than patients from extracorporeal anastomosis group,with a significant difference(P<0.05),while there was no significant difference in the incidence of overall complications,Clavien-Dindo gradeⅢ-Ⅳcomplications,abdominal infection(both with or without anastomotic leakage),anastomotic leakage,and wound infection between the two groups(P>0.05).(3)In the intracorporeal anastomosis group,patients undergoing modified surgery had a shorter operation time,less intraoperative bleeding,and a decreased incidence of overall complications and wound infection than patients undergoing unmodified surgery,with a significant difference(P<0.05).Conclusion When the specimen extraction site in laparoscopic right hemicolectomy was modified from the upper left abdomen main operation site to the mid-lower abdomen observation site,the rate of wound infection in intracorporeal anastomosis was significantly decreased,suggesting avoid choosing the main operation site as the specimen extraction site to decrease the risk of wound infection.