后腹腔镜下右侧肾上腺切除术中央静脉解剖及变异特点分析

目的 分析和总结后腹腔镜下右侧肾上腺中央静脉的解剖特点和变异情况,探讨后腹腔镜下处理该类血管安全和有效的方法。方法 回顾分析2016年9月至2019年3月由同一术者完成的61例后腹腔镜右侧肾上腺切除术的患者资料。术中使用“三层面”技术进行肾上腺的解剖分离,以下腔静脉作为解剖标志,对右侧肾上腺中央静脉予以仔细充分的游离暴露后在直视下用Hem-o-lok夹闭离断。结果 61例手术均成功完成,2例因肿瘤粘连严重中转开放。其中57例肾上腺中央静脉为正常解剖结构,而其中4例中央静脉有变异(6.56%),变异情况如下:仅有一支中央静脉汇入肝静脉1例;存在两支中央静脉,均汇入下腔静脉2例;存在两支中央静脉,一支直接汇入下腔静脉,另一支汇入肝静脉1例。术中1例出现腹膜破裂但未中转开放(1.64%),2例出现术后高热(38.5℃)(3.28%),无其他并发症发生。平均手术时间(83±27)min,平均术后住院天数(3.52±0.77)d。术后病理示:皮质腺瘤53例(86.89%),囊肿4例(6.56%),嗜铬细胞瘤3例(4.92%),淋巴管瘤1例(1.64%)。结论 熟悉后腹腔镜下右侧肾上腺的血管解剖以及变异情况对术中准确定位中央静脉至关重要,可以有效降低手术风险,保证手术的安全进行。     

腹腔入路腹腔镜根治性肾切除术中左肾静脉复合体的应用解剖

目的探讨经腹腔入路腹腔镜根治性肾切除术(T-LRN)中左肾静脉复合体的解剖特征及其应用价值。方法 2012年1月至2022年12月, 对有手术指征的左肾肿瘤患者实施T-LRN并全程录像。观察左肾动脉定位过程, 记录左肾静脉的位置、数目及其属支结构, 包括左生殖静脉、肾上腺中央静脉和腰静脉的呈现、走行及终止点, 目测血管径宽, 记录相关的手术并发症。结果男114例、女72例入组, 186例T-LRN手术均顺利。左肾动脉的定位过程中, 检出左肾静脉189支(183例1支, 3例2支), 径宽中位数12.1(7.8～16.3) mm, 位于肾动脉主干前方;左生殖静脉192支(180例1支, 6例2支), 血管径宽2.6(1.3～4.9) mm, 直行汇入左肾静脉;左肾上腺中央静脉189支(183例1支, 3例2支), 径宽2.5(1.6～3.1) mm, 直行汇入左肾静脉;检出179支(58例0支, 128例为1～4支)腰静脉, 径宽2.8(0.8～6.2) mm, 多止点斜行汇入左肾静脉。静脉复合体血管损伤10例, 含7例腰静脉出血, 予以夹闭或缝扎。结论左肾静脉复合体是左侧T-LRN术中...     

膈下静脉在后腹腔镜单层面下左侧肾上腺切除术中的应用价值

目的探讨后腹腔镜单层面下以膈下静脉为标志的肾上腺切除术在治疗左侧肾上腺疾病中的临床可行性及意义。 方法回顾性分析2015年7月至2016年12月48例行后腹腔镜左肾上腺切除患者的临床资料,男21例,女27例,平均年龄43岁。手术采用经肾外上方肾周脂肪囊与腰大肌筋膜间相对无血管的腰肌前平面入路,以左膈下静脉为解剖标志寻找并处理中央静脉进行左侧肾上腺切除。 结果本组48例手术均顺利完成。平均手术时间28 min,平均术中出血量20 ml,肠道功能恢复时间与下床活动时间分别为20 h和16 h,平均术后住院天数5 d。除2例腺瘤与1例皮质增生患者术后6个月血压控制欠佳外,其余患者临床症状均消失或明显改善。 结论后腹腔镜单层面左侧肾上腺切除术中,选择膈下静脉作为解剖标志,可快速定位控制中央静脉,减少术中出血及血压波动。     

下腔静脉在后腹腔镜右侧肾上腺切除术中作为解剖标志的应用探讨

目的基于对右侧肾上腺血管的手术经验总结,探讨后腹腔镜右侧肾上腺切除术中以下腔静脉为解剖标志准确分离出肾上腺动静脉层面的临床可行性及意义。 方法回顾性分析2020年1月至2021年9月,临沂市人民医院收治的36例右侧肾上腺腺瘤患者,均行后腹腔途径手术,手术由同一名手术医师(高年资主治医师,肾上腺总手术量大于300例)完成,以下腔静脉为解剖标志寻找并处理肾上腺动静脉并切除或部分切除右侧肾上腺。 结果本组36例手术均顺利完成。平均手术时间32 min,平均术中出血量20 ml,平均下床活动时间为术后16 h,平均术后住院时间2.4 d。 结论后腹腔镜下右侧肾上腺手术过程中以下腔静脉为解剖标志进行肾上腺血管的解剖分离,可将肾上腺动静脉的前后层次关系安全显露,有利于准确控制中央静脉、更好地显露手术视野和减少术中出血。     

双肾上腺中央静脉一例

肾上腺血管解剖变异并非常见,双肾上腺中央静脉更为罕见,但肾上腺血管变异增加了肾上腺手术的风险和难度,易造成误伤或遗漏.我们收治1例左侧肾上腺肿瘤患者,该患者为双肾上腺中央静脉,行后腹腔镜肾上腺肿瘤切除术,手术顺利,现结合文献报道如下. 患者男性,43岁.因"左侧腰痛半个月"在外院行CT检查,显示左输尿管结石,左肾上腺肿瘤.患者高血压病史10年,最高160/110 mmHg(1 mmHg =0.133 kPa).体检:左肾区叩击痛(+),左下腹输尿管走行区压痛.     

不阻断肾动脉的胡桃夹现象的手术治疗

目的：提高对胡桃夹现象（左肾静脉压迫综合征）的认识，改进治疗胡桃夹现象的手术方法。方法：对2例临床主要表现为反复发作肉眼血尿、1例表现为重度左侧精索静脉曲张的胡桃夹现象患者均行不阻断动脉的左肾静脉重建术，即在生殖腺静脉、肾上腺静脉与腔静脉之间阻断肾静脉，阻断部分腔静脉，袖状切除肾静脉起始处的腔静脉，将肾静脉下移并与纵形切开的腔静脉相吻合。结果：3例术后血尿均消失，曲张的精索静脉消失，术后尿量、肌酐均无变化，痊愈出院，平均随访6个月（2～12个月），症状均无复发。结论：左肾静脉重建手术是治疗血尿的有效方法，掌握熟练的血管吻合技术情况下，不阻断肾动脉在生殖腺和。肾上腺中央静脉以近阻断肾静脉进行肾静脉重建术是可行的，肾脏无冷热缺血时间，从而可减少肾功能损害。     

国人下腰椎前方血管解剖结构特点和入路分型

目的研究国人下腰椎前方血管与椎间隙之间的解剖特点，并进行解剖结构分型，为下腰椎前路椎间融合手术入路，尤其是腹腔镜下手术入路的选择提供解剖学依据。方法随机抽取94例国人腰椎MRI片，观察腰3-4、腰4-5，腰5-骶1椎间隙横断面前方的大血管解剖结构，判断腹主动脉的分叉位置和左髂总静脉与下腔静脉汇合位置，并进行解剖结构分型。结果根据腹主动脉分叉、左髂总静脉与下腔静脉汇合点与腰。椎间隙的上边缘之间的关系，确定4种类型。21例(22.3％)被归为A类(低分叉／低汇合)，34例(36．2％)被归为B类(高分叉／高汇合)，38例(40．4％)被归为C类(高分叉／低汇合)，1例(1．1％)被归为D类(低分叉／高汇合)。在腰5-骶1间隙腹主动脉均已分叉，左髂总静脉均未汇合。男女之间无显著性差异。结论下腰椎前方血管解剖位置具有多变性，以腰4-5椎间隙为著，使腹腔镜下手术入路变的复杂。术前常规腰椎。MRI图像能用来进行血管解剖位置的分类，并设计最佳的手术入路。     

CT血管成像结合图像融合技术在术前肾血管系统评估中的价值

目的 探讨CT血管成像(CTA)结合图像融合技术在肾脏手术前肾血管系统解剖学评估中的临床应用价值.方法 20例活体供肾者及12例超声提示左肾占位患者行CT平扫和动脉早期、动脉晚期及实质期3期动态增强扫描,数据采用Volume viwer 2软件包进行三维重建.由1位放射科及1位泌尿外科主任医师共同对左.肾动静脉的容积再现(VR)融合图像进行评阅,并与腹腔镜操作者术中所见进行对照,评价其在左肾动静脉解剖术前评估中的敏感性和特异性及应用图像融合技术的优势.结果 CTA能准确显示左肾动静脉系统的解剖变异.以术中所见为参考,5例左肾静脉主干变异均检出.且能准确显示左肾静脉属支,包括左肾上腺静脉、左性腺静脉及汇入左肾静脉的腰静脉,其敏感性分别为90%(27/30)、84%(26/31)及87%(20/23),特异性均为100%.诊断左侧副肾动脉的敏感性为90%(9/10),特异性为100%.VR融合图像诊断左肾动脉提前分支4例,术中仅诊断3例.应用CTA结合图像融合技术克服了以往VR图像不能清楚显示肾静脉系统的整体解剖及不能同时清楚显示肾动静脉系统解剖的缺点.结论 CTA结合图像融合技术能同时清楚准确地显示肾动静脉系统的解剖信息,在肾脏手术术前评估中有重要价值.     

多层螺旋CT在活体肾移植供肾评估及取肾手术方式选择中的应用

目的 评价多层螺旋CT(MSCT)在活体肾移植供肾及取肾手术方式选择中的应用价值.方法 90例活体肾移植供者接受了MSCT平扫及动脉期、静脉期和排泄期的扫描.采用最大密度投影和容积再现技术进行血管成像,所有MSCT图像均由2位影像医师盲法下独立进行分析和评价.根据重建的CT图像,影像医师与肾移植医师进行讨论,选择左肾还是右肾作为供肾,并确定采用腹腔镜下取肾手术或是开放式取肾手术.结果 90例供者中,78例接受了左肾切取术,其中71例左侧供肾无明显变异者接受了常规腹腔镜下取肾手术,7例两侧肾脏均存在如副肾动脉、多支肾静脉,或者肾静脉位于腹主动脉后方等较明显变异,接受了左肾开放式取肾手术;12例因左肾存在明显变异,接受了右肾切取术,均行手辅助腹腔镜下取肾手术.所有术中记录的肾血管及集尿系统的解剖结构与术前MSCT评价一致,其准确率为100％.2位影像医师在评价肾动脉、肾静脉和集尿系统中显示了很好的一致性.90例取肾手术全部成功,移植术后受者未发生肾静脉血栓形成等血管并发症.结论 MSCT作为活体肾移植供者术前评价“一站式”检查方法,可以为供肾和取肾手术方式的选择提供准确、有价值的信息.     

后腹腔镜解剖性肾上腺切除术

目的介绍后腹腔镜解剖性肾上腺切除术的手术方法及临床效果。方法2000年2月至2005年10月,对800例患者采取后腹腔镜解剖性肾上腺切除术。常规制备后腹腔操作空间。切开Gerota筋膜后,按顺序分别进入3个相对无血管解剖层面进行分离。第一分离层面位于肾脏内上方脂肪囊与前层Ger0ta筋膜之间,此层面可以在手术初期快速找到肾上腺;第二分离层面位于肾外上方脂肪囊与后层Gerota筋膜之间;第三分离层面位于肾上腺下方与肾上极之间。最后处理肾上腺中央静脉。依术前诊断和术中情况选择行肾上腺全切或次全切术。结果除1例嗜铬细胞瘤(肿瘤直径7.8 cm)患者因肾上腺肿瘤与肝脏及下腔静脉粘连紧密行中转开放手术外,全部手术均成功完成。平均手术时间(45±19)min,平均术中出血量(25±11)ml。恢复饮食和下床活动时间分别为1.2 d和1.0 d。12例(1.5%)出现术后皮下气肿、皮下血肿或切口感染。除6例特发性肾上腺增生患者术后1年高血压复发外,其余患者临床症状均消失或明显好转。结论后腹腔镜解剖性肾上腺切除术解剖层次清楚,术野清晰.疗效确切,为肾上腺外科疾病的治疗提供了更加安全的选择。     

Confluence of the right adrenal vein with the accessory right hepatic veins

Confluent drainage of the right adrenal vein and large accessory right hepatic veins was encountered during a laparoscopic right adrenalectomy. In a review of previous reports of laparoscopic adrenalectomies we found no mention of this finding. However, an anatomic study reported that the right adrenal vein joins with an accessory right hepatic vein in as many as 22% of individuals. A complete understanding of the anatomic variations in the drainage of the right adrenal vein is required for the safe performance of laparoscopic right adrenalectomy. Received: 31 October 1995/Accepted: 6 December 1995     

Vascular and bowel complications during retroperitoneal laparoscopic surgery

PURPOSE: We report on vascular and bowel complications during major retroperitoneal laparoscopic renal and adrenal surgery. MATERIALS AND METHODS: A total of 404 patients underwent retroperitoneoscopy for various renal and adrenal pathology between July 1997 and February 2001. The occurrence of intraoperative vascular and bowel injuries, specific intraoperative circumstances, management techniques and outcomes were evaluated. RESULTS: There were 7 vascular injuries (1.7%) and 1 bowel injury (0.25%), which involved the right adrenal vein (2), left renal vein (2), right renal vein (1), right renal artery (1), inferior vena cava (1) and a superficial, small serosal injury to the duodenum (1). Of these 8 cases 5 (63%) had been treated prior with major open intra-abdominal surgery. Average blood loss for patients with vascular injuries was 1,186 cc (range 300 to 3,000). Of the 8 cases 1 was converted to open surgery and in another 2 cases the vascular injury was controlled through the extraction incision, which had already been created. Retroperitoneoscopic control and repair without open conversion were possible in each of the most recent 5 cases. Of the 404 cases open conversion has not been necessary for control of vascular or bowel complications in the most recent 200 cases, demonstrating the impact of the learning curve. CONCLUSIONS: During major renal and adrenal retroperitoneoscopic surgery our incidence of vascular and bowel injuries was 1.7% and 0.25%, respectively. With experience inadvertent vascular and bowel injuries can be efficaciously controlled retroperitoneoscopically despite the somewhat small operative field available.     

Laparoscopic nephrectomy in patients with renal vein and/or inferior vena cava anomalies: Video presentation

Abstract:   Laparoscopic nephrectomy is a standard surgery for the treatment of many types of renal tumor, renal pelvic tumor, and benign disease. Renal vein and inferior vena cava anomalies are not uncommon, having been detected at an incidence of 2–17%. With the increasing number of patients undergoing laparoscopic nephrectomy, surgeons have more opportunities to encounter major anomalies of the renal vein and inferior vena cava. This video presents images of the management of the renal pedicle in laparoscopic nephrectomy in cases where there were anomalies of the renal vein and inferior vena cava.
Patient 1 had left renal tumor with the left inferior vena cava, patient 2 had left ureteral tumor with double inferior vena cava, patient 3 had left renal tumor with double inferior vena cava and a circumaortic renal vein, patient 4 had left renal tumor with a retro-aortic renal vein, and patient 5 had left renal tumor with a circumaortic renal vein. Multiple renal arteries were present in patients 3, 4, and 5.
In laparoscopic nephrectomy complicated by anomalies of the renal vein and inferior vena cava, (i) surgical staff should be alert for the potential presence of aberrant veins and multiple renal arteries that may not be visualized in preoperative imaging. (ii) An anterior transperitoneal approach is well-suited in the understanding of positional relationships of vessels and anatomical landmarks in cases of vascular anomalies. (iii) With recent advances in diagnostic imaging modalities, such as multislice computed tomography (CT) and 3-D CT, it has become easier to identify the major arterial and venous anomalies. However, intraoperative observation and assessment remain important and mandatory in the management of smaller anomalous vessels accompanied by major anomalies.     

腹腔镜下微创手术治疗肾癌合并高位肝后下腔静脉癌栓

目的探讨腹腔镜下微创手术治疗肾癌合并高位肝后下腔静脉癌栓的临床经验和文献分析。 方法女性患者,61岁,临床诊断：右肾癌合并高位肝后下腔静脉癌栓。术前全面评估手术风险,组织多学科会诊为患者制定详尽的围手术期治疗与护理方案,拟行腹腔镜下右侧肾癌根治性切除+高位肝后下腔静脉癌栓取出+腹膜后淋巴结清扫术。术后医护密切配合严密观察患者病情变化,进行围手术期观察处理与护理。 结果手术顺利完成,手术时间390 min,无中转开放手术。术中完全游离右侧和左侧肾静脉、肝后下腔静脉直达第二肝门水平远端,近右肾静脉处下腔静脉内侧壁剪开静脉壁,癌栓下部小灶性侵犯静脉壁,切除部分腔静脉壁完整取出癌栓,恢复左侧肾静脉、腔静脉血流回流无障碍。术后病理提示符合透明细胞癌,癌组织侵犯肾窦脂肪,腹膜后淋巴结（-）。术后随访6个月未见肿瘤复发。 结论腹腔镜下微创手术治疗肾癌合并高位肝后下腔静脉癌栓安全可行,多学科协助模式为疑难复杂病例提供了一种新的选择,值得临床进一步推广。     

Variations of hepatic veins: helical computerized tomography experience in 100 consecutive living liver donors with emphasis on right lobe

Anatomical variations in the venous system of liver are not a rarity. A prospective helical computerized tomography (CT) study was undertaken to determine the prevalence of surgically significant hepatic venous anatomic variations among 100 consecutive living liver donors. The studies evaluated the ramification pattern of hepatic veins, the presence of accessory hepatic veins, and of segment 5 or 8 veins (or both) draining into middle hepatic vein. These data obtained by CT influenced surgical planning. Sixty-four donors donated their right lobes and 24 donors, left lateral segments. Only one donor candidate was refused due to combined hepatic and portal venous variations accompanied by multiple bile ducts. Eleven donors were also refused due to reasons other than anatomical variations. Seventeen segment 5 and 17 segment 8 veins draining into middle hepatic vein were anastomosed to inferior vena cava in 23 (36%) of the right lobe liver transplantations. The middle hepatic vein was harvested in only one of the donors. Among the 100 cases, 47 had accessory right inferior hepatic veins, 13 of which were multiple. Twenty-two of the right lobe grafts required surgical anastomoses of these accessory hepatic veins (34%). An isolated hepatic vein anomaly or the presence of accessory hepatic veins are not contraindications to be a living liver donor candidate. However, preoperative knowledge of vascular variations alters surgical management. Helical CT is a valuable tool to delineate the hepatic venous anatomy for surgical planning in living liver donors.     

Renal cell carcinoma with a huge solitary metastasis to the contralateral adrenal gland: A case report

Renal cell carcinoma (RCC) is capable of metastasizing to several organs. Synchronous isolated contralateral adrenal metastasis of the primary RCC is, however, very rare. Herein we report a case of RCC with a huge solitary metastasis to the contralateral adrenal gland that was surgically treated. We scheduled nephrectomy for the left primary RCC and adrenalectomy for the right adrenal tumor. However, at surgery we found a huge right adrenal tumor that had invaded the right kidney, right renal vein, and inferior vena cava. Therefore right nephrectomy was performed simultaneously with resection and reconstruction of the inferior vena cava. Pathological findings demonstrated that the left renal tumor and right adrenal tumor had the same histology. Although the patient required hemodialysis, he remains well at six months postoperatively. So far, there have been only two cases of a solitary contralateral metastatic adrenal tumor that was larger than the primary RCC, thus the present case is the third one.     

A rare anomaly of left renal vein drainage into the left common iliac vein: A case report

IntroductionHerein, we describe a case of sigmoid colon cancer with a rare anomaly of the left renal vein located between the inferior mesenteric artery (IMA) and the left common iliac artery.Case presentationA 57-year-old woman with sigmoid colon cancer underwent three-dimensional computed tomography angiography for a preoperative assessment; the results revealed a rare variant of the left renal vein. There were two left renal veins: one retroaortically drained into the inferior vena cava, and the other was located between the IMA and the left common iliac artery and drained into the left common iliac vein. Laparoscopic sigmoid colectomy was performed safely while carefully avoiding any injury to the left renal vein located posterior to the IMA.DiscussionSeveral variations of the left renal vein have been reported, such as retroaortic or circumaortic left renal veins. The variants of renal vessels, which are frequently overlooked in the preoperative assessment, is rarely affected in colorectal surgery. However, if the surgeon is unaware of such renal vessel anomalies, an injury can occur, resulting in severe bleeding.ConclusionIt is important that surgeons identify retroperitoneal vessel variants before performing colorectal surgery.     

Prospective comparison of 3-dimensional volume rendered computerized tomography and conventional renal arteriography for surgical planning in patients undergoing laparoscopic donor nephrectomy

PURPOSE: We prospectively assessed the accuracy of 3-dimensional (3-D) volume rendered computerized tomography (CT) and conventional renal arteriography to visualize renovascular anatomy in patients undergoing laparoscopic donor nephrectomy. MATERIALS AND METHODS: A total of 60 consecutive patients undergoing laparoscopic donor nephrectomy (left side in 46 and right side in 14) prospectively underwent 3-D CT and renal angiography. A short videotape of 3-D CT was prepared using volume rendering software that demonstrated the anatomical location, number, anomalies and spatial interrelationships of the renal arteries and veins. These 3-D videotapes and arteriogram findings were directly correlated with intraoperative surgical findings at laparoscopy and during ex vivo bench preparation of the harvested kidney. The perceived intraoperative value of 3D-CT to delineate renovascular anatomical detail was scored subjectively by the laparoscopic surgeon for each case on a 10-point scale of 0--completely inaccurate to 10--completely accurate. RESULTS: There were no complications related to the 3-D CT protocol and volume rendering was successful in all patients. Three-D CT accurately identified the number of renal arteries in 59 patients (98%). In 1 patient with 3 renal arteries 3-D CT and arteriogram each identified only 2. In the 46 patients undergoing left donor nephrectomy 3-D CT accurately identified the number of veins and venous anomalies in 45 (98%), including 2 with a circumaortic left renal vein. Another case of circumaortic vein was misdiagnosed as 2 renal veins. On the right side in 14 patients 3-D CT accurately identified the renal veins in 13 (94%) and missed 1 vein in a patient with 2 renal veins. Angiography correctly identified the number of renal veins in only 52 cases (87%). Furthermore, it misdiagnosed all 3 cases of circumaortic left renal vein. The laparoscopic surgeon believed that 3-D CT accurately identified the location and anatomical interrelationship of the renal vessels with precision. Mean subjective score +/- SEM was 8.5 +/- 1 for the arterial system, 8.6 +/- 1.1 for the venous system and 9.2 +/- 0.5 for any vascular anomalies. CONCLUSIONS: Three-D CT accurately identifies renal vascular anatomy in a manner that may facilitate renal hilar dissection during laparoscopic donor nephrectomy, especially during the initial surgeon experience. This imaging modality integrates essential information from angiography, venography and excretory urography into a single study, and it can obviate the need for more invasive vascular imaging in most cases.