腹腔镜尾侧入路联合中间翻页式清扫右半结肠癌根治术效果分析

目的 探讨腹腔镜尾侧入路联合中间翻页式清扫(尾侧中间联合入路)右半结肠癌根治术的临床效果.方法 回顾性分析巩义市人民医院普外科2017-11—2020-09行腹腔镜右半结肠癌根治术的60例右半结肠癌患者的临床资料.分为尾侧中间联合入路组(观察组)和传统中间入路组(对照组),各30例.比较2组患者基线资料、术中情况、术后...     

从上到下“翻页式”腹腔镜右半结肠D_3根治术临床体会

目的:探讨经上下入路"翻页式"腹腔镜右半结肠D3根治性切除的手术路径要点及临床意义。方法:回顾分析2012年2月至2014年2月为102例右半结肠癌患者行经上下入路"翻页式"腹腔镜右半结肠D3根治术的临床资料。结果:95例(93.14%)患者顺利完成手术,7(6.86%)例中转开腹。术中清扫时间42~96 min,平均(78.2±11.3)min。术中出血量10~40 ml,平均(24.3±6.4)ml。清扫淋巴结11~46枚,平均(20.9±5.5)枚。术后肛门排气时间17 h~8 d,平均(64.8±27.3)h;术后住院7~13 d,平均(9.8±2.1)d。术后发生吻合口漏1例(0.98%)、切口脂肪液化2例(1.96%),均经治疗后痊愈,无围手术期死亡病例。结论:经上下入路"翻页式"腹腔镜右半结肠D3根治性切除术显露方便,对助手的腹腔镜经验要求较低,术中有良好的参照作为引导,清扫较流畅,很好地体现了"无瘤原则",达到了腹腔镜右半结肠D3根治手术的基本要求,且降低了腹腔镜右半结肠癌手术的难度,手术安全、可行,具有一定的临床实用价值。     

尾背侧入路在腹腔镜右半结肠癌根治术中的临床应用

目的探讨经尾侧入路腹腔镜右半结肠切除术的安全性和可行性。方法回顾分析2016年1月至2016年12月,我科收治的需进行腹腔镜右半结肠癌根治切除术患者22例。按照采用尾背侧中间入路10例(简称尾背侧组)和尾腹侧中间入路12例(简称尾腹侧组);两组患者均进行腹腔镜右半结肠切除术,对两组患者的手术时间、手术出血量、淋巴结清扫个数、切除的标本质量、术后首次排气时间及吻合口瘘发生情况进行记录,同时比较结果。结果尾背侧组手术时间178.6±16.2 min、术中出血83.2±8.4 mL与尾腹侧组205.0±20.0 min、100.7±13.3 mL比较,差异具有统计学意义(P0.05)。尾背侧组清扫淋巴结数目15.7±1.9枚,术后排气时间2.8±0.5 d、切除标本中系膜保留完整10例、无吻合口瘘,无中转开腹、住院日12.6±1.2 d;尾腹侧组16.3±1.7枚、2.8±0.5 d、12例、0例、0%、平均住院日12.7±1.1 d比较,差异无统计学意义(P0.05)。手术标本系膜完整两组均完整无破损,尾背侧组与尾腹侧组各出现术后并发症1例(淋巴瘘),均于术后第4天出现,保守治疗3天后治愈。结论选择尾背侧入路在腹腔镜右半结肠癌根治切除术是安全的,可行的。     

尾侧联合中间入路腹腔镜右半结肠癌根治术的临床应用

探讨尾侧联合中间入路腹腔镜右半结肠癌根治术的安全性及有效性。回顾性分析漯河市中心医院2015年1月—2019年12月实施的腹腔镜右半结肠癌完整结肠系膜切除术74例患者的临床病例资料,比较两组患者的基线资料、手术相关指标及术后恢复指标。两组患者的基线资料、淋巴结清除数量及术后恢复指标相比,差异无统计学意义(P0.05);尾侧组和中间组患者的手术时间[(140±20)min比(165±25)min]和出血量[(75±28 mL)比(105±35)mL]相比,差异有统计学意义(P0.05)。尾侧联合中间入路腹腔镜右半结肠癌根治术安全、可行。     

完整结肠系膜切除在中间入路右半结肠癌D3根治术中的临床应用

目的 探讨完整结肠系膜切除在中间入路右半结肠癌D3根治术中临床应用的可行性和有效性.方法 回顾性分析2010年2月至2012年6月我院胃肠肿瘤外科完整结肠系膜右半结肠癌D3根治术患者42例的临床病理资料,其中开腹手术20例,腹腔镜手术22例.结果 42例患者平均手术时间(146.43±30.73)min(90～240min),术中平均出血量(152.86±38.97)ml(100～300ml),术后平均住院时间(11.5±2.45)d(6～16d),无严重并发症,无住院期间死亡病例.中位淋巴结清扫数17.5枚(12～50枚),淋巴结阳性率11.43%,中位随访时间19个月(1～28个月),肿瘤复发率为2.38%.结论 完整结肠系膜切除在中间入路右半结肠癌D3根治术中的临床应用具有可行性和有效性.     

头侧-尾侧-中间入路行腹腔镜右半结肠癌根治术的临床3年随访研究

目的探讨头侧-尾侧-中间入路行腹腔镜右半结肠癌根治术的临床3年随访研究。方法回顾性分析2015年1月至2017年4月收治的83例右半结肠癌患者资料,均接受腹腔镜右半结肠癌根治术治疗。根据术中入路方式不同分为两组,将中间入路的40例患者纳入中间入路组,将以头侧-尾侧-中间入路的43例患者纳入混合入路组。采用SPSS 24.0软件进行数据处理,手术相关指标、术后恢复情况等计量资料以■表示,采用独立t检验;并发症、复发率及转移率等计数资料采用χ~2检验,P0.05为差异有统计学意义。结果混合入路组手术时间、术中出血量均比中间入路组少(P0.05);两组肛门排气时间、初次饮食时间、腹腔引流时间、住院时间、术中淋巴结清扫数量、术后3年复发率及转移率相比,差异均无统计学意义(P0.05)。混合入路组并发症总发生率比中间入路组低(7.0%vs. 22.5%)。结论与中间入路相比,头侧-尾侧-中间入路行腹腔镜右半结肠癌根治术可有效缩短手术时间,减少术中出血量,进而降低术后并发症风险。     

腹腔镜右半结肠癌根治术中间入路手术体会

探讨腹腔镜中间入路法右半结肠癌根治术的手术要点、安全性及临床应用。回顾分析2015年1月—2018年4月行右半结肠癌根治术66例患者,其中开腹33例,腹腔镜中间入路33例。腹腔镜手术以回结肠血管为起始入路标志,以肠系膜上静脉为解剖学标志,建立正确的外科平面进行系膜血管的解剖及淋巴结清扫。比较两组患者的手术时间、术中出血量、术后肛门首次排气时间、术后住院时间、淋巴结清扫数目及并发症情况。结果显示,腹腔镜中间入路与开腹侧方入路比较,其在术后肛门首次排气时间、术后住院时间、淋巴结清扫数目有优势,并发症和术中出血量减少,但手术时间延长。结果表明,腹腔镜右半结肠癌中间入路完整肠系膜切除,手术安全,创伤小,可行性高。     

腹腔镜右半结肠癌根治术三种入路的效果比较

比较腹腔镜右半结肠癌根治术三种入路的临床应用效果。选取2016年1月至2020年3月我院收治的60例行腹腔镜右半结肠癌根治术的患者作为研究对象,根据手术入路分为三组,传统中间入路(A组)26例、尾侧联合中间入路(B组)21例、头尾联合入路(C组)13例。三组患者基线资料比较,差异无统计学意义(P0.05),具有可比性。A组患者手术时间、术中失血量显著高于B组、C组,差异有统计学意义(P0.05)。三组患者淋巴结清扫数目、中转开腹率、首次排气时间、腹腔引流管留置时间、术后住院时间、并发症发生率等比较,差异无统计学意义(P0.05)。三组共4例出现术后并发症,包括2例切口感染、1例肠梗阻、1例尿路感染,程度均较轻,给予对症处理后痊愈或好转,无1例围手术期死亡。腹腔镜右半结肠癌根治术的传统中间入路、尾侧联合中间入路、头尾联合入路都安全、可行,尾侧联合中间入路、头尾联合入路手术时间和出血量更少,操作相对容易,值得临床推广。     

尾内侧入路单向环路式手术与腹腔镜中间入路手术治疗右半结肠癌的对照研究

目的探讨尾内侧入路单向环路式手术与腹腔镜中间入路手术治疗右半结肠癌的临床效果。方法纳入2014年1月至2015年12月本院收治的60例右半结肠癌患者作为研究对象,随机分为对照组与观察组,每组各30例。对照组行常规腹腔镜中间入路手术,观察组行尾内侧入路单向环路式腹腔镜手术。比较两组手术相关情况、术后恢复及院外1年生存情况。结果术中均未发生中转开腹病例。两组手术时间和淋巴结清扫数目差异均无统计学意义(均P0.05);观察组术中出血量少于对照组,观察组术后肛门首次排气时间、进流质饮食时间、拔管及住院时间均短于对照组(均P0.05)。观察组术后1年无瘤生存率高于对照组(P0.05),两组1年总生存率差异无统计学意义(P0.05)。结论腹腔镜尾内侧入路单向环路式手术用于右半结肠癌与常规中间入路均能获得满意的肿瘤根治效果,但前者有助于减轻对腹腔脏器组织的损伤,促进术后早期康复,降低术后复发转移风险。     

全结肠系膜切除术在腹腔镜辅助右半结肠癌根治术中的应用

目的探讨全结肠系膜切除术(complete mesocolic excision,CME)在腹腔镜辅助右半结肠癌根治术中的安全性。方法回顾性分析2012年1月~2013年6月接受CME腹腔镜辅助右半结肠癌根治术40例的临床资料,选取2011年1月~2011年12月同一手术组施行的开腹右半结肠癌根治术38例作为对照组,比较2组患者术中、术后情况。结果腹腔镜组清扫淋巴结(22.1±7.8)枚,明显多于开腹组(18.6±4.3)枚(t=2.436,P=0.017),其中Ⅱ期淋巴结清扫数目无统计学差异(t=0.758,P=0.454),Ⅲ期腹腔镜组明显多于开腹组[(23.0±6.0)枚vs.(18.2±5.1)枚,t=2.699,P=0.000]。2组患者手术时间、术中出血量差异无统计学意义(t=0.716,P=0.476;t=-1.547,P=0.126)。腹腔镜组术后引流管拔出时间[(9.0±1.3)d vs.(10.3±2.2)d,t=-2.950,P=0.004],术后排气时间[(3.1±1.2)vs.(4.8±1.4)d,t=-5.767,P=0.000],术后进食时间[(4.3±0.8)d vs.(6.2±1.3)d,t=-7.817,P=0.000],术后住院时间[(10.6±2.8)d vs.(15.8±4.6)d,t=-6.065,P=0.000],术后并发症发生率(10.0%vs.28.9%,χ2=4.504,P=0.034)均显著短于/低于开腹组。结论 CME在腹腔镜辅助下右半结肠癌根治术中安全、可行,可保证切除系膜的完整性和清扫更多的淋巴结,但并不会增加手术风险和术后并发症发生率。     

以肠系膜上静脉为标识中线入路法在右半结肠联合胰十二指肠切除术中的应用

目的探讨以肠系膜上静脉为标识的中线入路法在右半结肠联合胰十二指肠切除术中的安全性与有效性。方法回顾性分析2016年1月至2019年7月河南省肿瘤医院普外科采取以肠系膜上静脉为标识的中线人路法行肝曲结肠癌(T4b)右半结肠联合胰十二指肠切除术13例患者的临床病理资料,以肠系膜上静脉为标识向上延伸作为肿瘤切除的内侧界。结果本组13例患者均顺利完成手术。平均手术时间(249±27)min,平均术中出血量(442±129)ml,平均清扫淋巴结(20±4)枚。术后发生胰漏2例,胃瘫1例,无吻合口狭窄、腹腔感染、肠梗阻、肠系膜损伤等并发症。术后平均住院时间(23.2±9.4)d。结论以肠系膜上静脉为标识中线人路法行右半结肠联合胰十二指肠切除术符合无瘤原则和结肠系膜完整切除原则,并且安全、可行。     

以回结肠静脉为标记中线入路并左手控制技术在右半结肠切除术中的应用

目的探讨以回结肠静脉为标记中线入路并左手控制技术在右半结肠切除术中的应用。方法对2011年10月至2012年10月18例以回结肠静脉为标记中线入路并左手控制技术（观察组：自下而上处理肠系膜上静脉）右半结肠切除术患者资料进行回顾性分析,并与同期实施以肠系膜上静脉为标记中线入路（对照组：自上而下处理肠系膜上静脉）右半结肠切除术的20例患者的手术时间、术中出血量、手术效果及安全性进行比较。结果观察组与对照组平均手术时间分别为（46．7±6．3）min及（106．5±12．7）min,差异有统计学意义（P=0．024）;术中平均出血量分别为（55．8±9．4）mL和（60．5±11．5）mL,差异无统计学意义（P=0．35）。观察组无肠系膜上静脉损伤病例,对照组2例患者出现肠系膜上静脉损伤。观察组淋巴结清扫数平均（11．4±5．5）个,对照组淋巴结清扫数平均（10．2±4．7）个,观察组和对照组清扫淋巴结效果相当（P=0．83）,差异无统计学意义。结论以回结肠静脉为标记中线入路并左手控制技术能够减少肠系膜上静脉损伤机会,降低手术难度,缩短手术时间,增加手术安全性。     

腹腔镜中间入路逆行法右半结肠癌D3根治术的手术要点与难点分析

目的探讨腹腔镜中间入路逆行法右半结肠癌D3根治术的手术方法。方法2008年11月～2012年6月,对20例回盲部、升结肠、结肠肝曲癌,采用腹腔镜中间入路逆行法,以解剖肠系膜上静脉进行淋巴结清扫,进入正确的外科平面,最后离断外周固定装置而行右半结肠切除术。结果17例用腹腔镜中间入路逆行法完成手术,3例中转开腹（1例游离肠系膜血管根部时出血,2例腹腔粘连）。17例腹腔镜手术时间126～186rain,平均145．3min,术中出血60～200ml,平均85ml,清扫淋巴结12～18枚,平均16．5枚,阳性淋巴结0～7枚,平均4．4枚,术后24～72h恢复胃肠功能,术后住院8～13d,平均11d,均顺利恢复,术后切缘病理均无肿瘤残余。术后均予以化疗,随访6～26个月,平均20个月,无复发、转移。结论掌握腹腔镜中间入路逆行法右半结肠癌D3根治术的要点与难点,可简化手术程序,节省手术时间,改善手术效果,该方法安全、有效,易于推广。     

腹腔镜右半结肠癌根治术中使用血管结扎束34例病例报告

目的探讨腹腔镜右半结肠癌根治术中使用血管结扎束(Liga Sure)进行手术的效果及短期安全性评价。方法回顾性分析2013年11月至2017年2月使用血管结扎束进行的34例腹腔镜右半结肠癌根治术患者的临床资料。收集患者术中、术后资料,分析患者使用血管结扎束的效果及安全性。结果纳入的34例患者均顺利完成手术,手术时间(174.0±28.3)min,出血量(34.0±33.5)ml,无术中并发症,无损伤肠系膜上血管主干病例发生;2例患者发生乳糜漏,2例患者出现系膜破损,术后平均住院时间(6.0±4.6)d。平均获检淋巴结数量为24枚,阳性约1.2枚,共有15例患者伴有淋巴结转移。结论通过上述结果,使用Liga Sure进行的病例中无严重并发症发生,出血少,手术时间短,Liga Sure可用于腹腔镜右半结肠癌根治术的游离,短期效果及安全性均较好。     

中间入路法腹腔镜右半结肠癌根治术55例临床体会

目的:探讨腹腔镜中间入路法右半结肠癌根治术的手术要点及临床疗效。方法:回顾分析2008年1月至2013年1月55例行腹腔镜下右半结肠癌根治术患者的临床资料,术中以回结肠血管为起始入路标志,以肠系膜上静脉为解剖学标志,建立正确的外科平面进行系膜血管的解剖及淋巴结清扫。结果:54例患者均顺利完成腹腔镜辅助根治性右半结肠切除术,1例(1.82%)中转开腹,手术时间平均(113.5±13.8)min,术中出血量平均(75.2±16.5)ml,切除标本长度平均(15.4±5.26)cm,淋巴结清扫数量平均(16±3)枚,术后排气时间平均(3.5±1.8)d,恢复流质饮食时间平均(3.2±0.85)d,平均住院(9.75±1.5)d。术中无肠系膜上静脉、十二指肠、输尿管、生殖血管损伤,术后无切口感染、吻合口漏、腹腔脓肿等并发症发生。55例患者随访10~40个月,平均(25.5±2.3)个月,未发现吻合口复发、穿刺孔或辅助切口种植转移、远处转移等。结论:以回结肠血管为标志的中间入路法能快速准确地进入Toldt间隙及胰腺十二指肠前筋膜间隙,既能保证肿瘤的根治性,又能保证手术的安全性,具有较高的临床应用价值。     

Medially approached radical lymph node dissection along the surgical trunk for advanced right-sided colon cancers

Although laparoscopic surgery is one of the treatment options for colorectal cancer, certain technical problems remain unresolved for the radical dissection of regional lymph nodes (LNs), which is essential to improve treatment outcome. We present a safe procedure for laparoscopic right hemicolectomy to dissect the regional LNs along the superior mesenteric vein (SMV). The key characteristic of our procedure is that all right and middle colic vessels are cut along the surgical trunk using only a medial approach. First, the pedicle of ileocolic vessels is identified and the mesocolon is dissected between the pedicle and the periphery of the SMV to expose the second portion of the duodenum. The ileocolic vessels are then cut at their roots. The ascending mesocolon is separated from the retroperitoneal tissues, duodenum, and pancreatic head up to the hepatocolic ligament cranially. The important detail in this procedure is the wide separation between the pancreatic head and the transverse mesocolon. This procedure uncovers the course of the right colic artery, veins, and the gastrocolic trunk [1]. The right colic artery and veins can then be safely cut at their roots. For an extended right hemicolectomy, the middle colic vessels can easily be identified below the lower edge of the pancreas and cut at their roots [2]. We performed curative resections in this manner for 16 consecutive patients with advanced right-sided colon cancer without any serious intraoperative complications. The median number of retrieved lymph nodes was 31 (range = 9–57). The median operative time and intraoperative blood loss were 274 min (range = 147–431 min) and 45 g (range = 0–120 g), respectively. The postoperative course of all patients was uneventful. Four of 16 patients had node-positive disease. With a median follow-up period of 272 days, all patients are alive without recurrence. We consider this a safe method for radical LN dissection during laparoscopic right hemicolectomy. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Laparoscopic Medial-to-lateral Approach for the Curative Resection of Right-Sided Colon Cancer

INTRODUCTION: Our previous randomized clinical trial comparing the laparoscopic medial-to-lateral dissection with the more classic lateral-to-medial approach for resection of rectosigmoid cancer showed that the medial approach reduces the operative time and the postoperative proinflammatory response. Besides the oncologic advantages of an early vessel division and a "no-touch" dissection, we feel that the longer the lateral abdominal wall attachments of the colon are preserved, the better the exposure and the easier the dissection. Encouraged by the above-mentioned positive findings, we therefore further conduct this phase II clinical trial to examine the feasibility and surgical outcomes regarding the utilization of this medial-to-lateral laparoscopic dissection approach for the curative resection of right-sided colon cancer. METHODS: A total of 104 patients (from December 2000 to January, 2005) with advanced right-sided colon cancer (TNM stage II: n = 56; stage III: n = 48) requiring a curative right hemicolectomy were subjected to the laparoscopic medial-to-lateral approach that included initial exploration and ligation of ileocolic, right colic, and middle colic vessels in no-touch isolation fashion, subsequent medial-to-lateral extension of retroperitoneal dissection along Gerota fascia, opening of lesser sac by transection of gastrocolic ligament, and the final mobilization of hepatic flexure and lateral attachments of ascending colon (Fig. 1). This study was approved by the institutional review committee of National Taiwan University Hospital. The surgical details were shown in the video. Postoperatively, adjuvant chemotherapy with Mayo Clinic Regimen was given in patients with stage III diseases. The functional recovery and surgical outcomes were prospectively evaluated. RESULTS: The laparoscopic medial-to-lateral approach for a curative right hemicolectomy can be preformed with acceptable operation time (192.6 +/- 32.8 min, mean +/- standard deviation) and little blood loss (48.4 +/- 14.4 ml) through a small wound (6.0 +/- 0.8 cm). The number of dissected lymph node was 16.0 +/- 2.8. The operative complications represented 5.7% of all cases, including anastomotic leakage in two cases (1.9%) and wound infection in four cases (3.8%). The patients have quick functional recovery, as evaluated by the length of postoperative ileus (60.0 +/- 12.0 h), hospitalization (9.0 +/- 1.5 days) and degree of postoperative pain (4.0 +/- 0.5, visual analogue scale). Besides the expenses covered by the National Bureau of Health Insurance in Taiwan, the patient had to pay an extra-expenses of NT$ 25,000.0 +/- 2,800.0 (1.0 US$ = 32.0 NT$). During the follow-up periods (median: 30 months, range 6-55 months), recurrence of tumor developed in 6 (10.7%) of stage II and 10 (20.8%) of stage III patients, with liver metastasis in six patients, lung metastasis in 4, liver and lung metastasis in 1, intraperitoneal recurrence in 2, bone metastasis in 1, brain metastasis in 1, and port-site recurrence in 1. CONCLUSIONS: By medial-to-lateral dissection method, the laparoscopic right hemicolectomy can be performed with technical efficiency, short convalescence, and acceptable short-term oncologic results. We therefore encourage the use of this approach for patients requiring a curative laparoscopic right hemicolectomy.     

The paraaortic lymphadenectomy with the lower mesenteric artery sceletonization for the sigmoid cancer treatment

43 patients with sigmoid cancer stage I--III were operated on. The mean operative time was 206.2±73.0 min, considering the sceletonization of the lower mesenteric artery together with the paraaortic lymphadenectomy took 28±9 min. The long-term follow-up was performed in all the patients. The median follow-up time was 39.35±13.1 months. 4 patients had died, 3 of them because of the cancer progression. The paraaortic lymphadenectomy with the lower mesenteric artery sceletonization is now considered to be the method of choice in treatment of sigmoid cancer. The operation is reasonably safe considering the rate of intra- and postoperative complication rate.     

Anatomic study of the superior right colic vein: its relevance to pancreatic and colonic surgery

BACKGROUND: This study was designed to describe the precise anatomic venous tributaries of the superior mesenteric vein with special emphasis on the superior right colic vein (SRCV), which is seldom mentioned in the literature. METHODS: Nine adult cadavers were dissected to define the venous tributaries of the superior mesenteric vein. The SRCV, middle colic vein, and right colic vein (RCV) were defined as those that drained from the marginal vein of the right flexure of the colon, the transverse colon, and the ascending colon, respectively. RESULTS: The SRCV was observed to drain from the right flexure of the colon to the confluence of the right gastroepiploic and superior pancreaticoduodenal veins and present the gastrocolic trunk of Henle (GTH) in 8 of 9 cases. The RCV terminated into the GTH in 4 cases. The SRCV, the RCV, and the middle colic vein formed a confluence and entered into the GTH in 1 case. CONCLUSIONS: The SRCV exits and drains from the right colonic flexure to the GTH in 89% of cases.