单孔加一孔腹腔镜辅助经肛全直肠系膜切除术的技术探索

Exploration of Single-Port Plus One-Port Laparoscopic Assisted Transanal Total Mesorectal Excision

目的:探讨单孔加一孔(single-port plus one-port, SILS + 1)腹腔镜辅助经肛全直肠系膜切除术(transanal total mesorectal excision, taTME)治疗低位直肠癌的安全性和可行性。方法:回顾性分析2021年3月~2022年3月期间重庆大学附属沙坪坝区医院行经SILS + 1腹腔镜辅助taTME手术治疗的8例低位直肠癌患者的临床资料。结果:8例病人中男性6例,女性2例,年龄(62.3 ± 14.1)岁,BMI为(23.8 ± 2.7) kg/m2,肿瘤距离肛缘(31.5 ± 10.7) mm,肿瘤直径(43.9 ± 7.8) mm。全组患者均利用回肠造口预切口及右下腹引流管预切口行SILS + 1腹腔镜辅助taTME手术,无中转开腹,无术中意外损伤及严重并发症发生。总手术时间为(223.1 ± 61.5) min,经腹操作时间为(150.5 ± 36.4) min,经肛操作时间为(80.1 ± 22.5) min,术中失血量(28.8 ± 13.6) mL,吻合口距齿状线距离为(9.4 ± 7.3) mm。全组患者术后大体标本长度为(155.0 ± 80.9) mm,直肠系膜均完整切除,淋巴结检出数目(18.1 ± 7.6)枚,远切缘长度(19.4 ± 3.2) mm,吻合口近、远端及环周切缘均未见癌细胞残留。所有患者术后第1天均开始饮水,第2天进流质饮食,术后7~9天拔除引流管,术后住院时间为8~15天。第2例患者术后第3天出现尿潴留,予以留置导尿,并口服“溴吡斯的明片”治疗30天后治愈。第6例患者术后第8天出现B级吻合口瘘,经局部冲洗引流,抗感染,肛门坐浴等保守治疗后治愈。全组患者无肠梗阻、腹腔感染以及肺部感染等并发症发生。术后随访24~36个月,无肿瘤复发转移及死亡病例。结论:SILS + 1腹腔镜辅助taTME治疗低位直肠癌近期疗效较好,降低单孔腹腔镜操作难度的同时,充分发挥经肛操作优势,且兼具美容效果。Objective: To explore the safety and feasibility of single-port plus one-port, SILS + 1) laparoscopic assisted transanal total mesorectal excision in low rectal cancer. Methods: From March 2021 to March 2022, eight low rectal cancer patients underwent SILS + 1 laparoscopic assisted taTME in our hospital. Results: All 8 patients received (SILS + 1) laparoscopic-assisted taTME and sigmoid-anal anastomosis. Of the 8 patients, 6 were male and 2 female;mean age was (62.3 ± 14.1) years old;body mass index was (23.8 ± 2.7) kg/m2;distance from tumor to anal edge was (31.5 ± 10.7) mm;diameter of tumor was (43.9 ± 7.8) mm. All the patients were successfully completed without conversion to laparotomy perioperative, with no accidental injury and severe complications in the operation. The mean total operative time was (223.1 ± 61.5) minutes;abdominal operation time was (150.5 ± 36.4) min, time of taTME was (80.1 ± 22.5) minutes, intra-operative blood loss was (28.8 ± 13.6) mL, the distance from anastomotic stoma to dentate line was (9.4 ± 7.3) mm. The length of the specimens was (155.0 ± 80.9) mm;all the mesorectum was complete, the mean number of lymph nodes dissected was (18.1 ± 7.6), The mean distal margin was (19.4 ± 3.2) mm, and the proximal, distal and circumferential margins were all negative. All patients start drinking water on the first day, and have fluid diet on the second day after operation. The drainage tube was removed 7 to 9 days after surgery. The postoperative hospital stay was 8 to 15 days. The second case developed urinary retention on the third day after the operation, and healed after 30 days by indwelling catheterization and oralling “Pyridostigmine Bromide Tablets”. The sixth patient developed grade B anastomotic leakage on the 8th day after operation, and was healed after conservative treatment such as local irrigation and drainage, anti-infection, and anal sitz bath. All the patients were followed up for 24 to 36 months, and no tumor recurrence transfer and death cases were observed. Conclusion: The method of SILS + 1 laparoscopy-assisted taTME has a good short-term curative effect in the treatment of low rectal cancer. While reducing the difficulty of single-port laparoscopic operation, it can give full play to the advantages of taTME, and has both cosmetic effects.