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。     

后腹腔镜下解剖性肾切除术405例经验总结

目的 探讨后腹腔镜下解剖性肾切除术的安全性和有效性,规范后腹腔镜下肾切除术术式. 方法回顾性分析后腹腔镜下解剖性肾切除术405例患者资料.男232例,女173例.平均年龄(57.2±14.2)岁.肾癌行后腹腔镜下根治性肾切除术228例,肾盂癌及输尿管癌分别行后腹腔镜下肾输尿管全长切除术96例及49例,肾脏良性疾病致肾功能丧失行后腹腔镜下肾切除术32例.根治性切除在Gerota筋膜外进行,切除界限背侧为Gerota筋膜与侧椎筋膜问、腹侧为Gerota筋膜与肾前融合筋膜间的潜在间隙;良性肾切除则直接切开Gerota筋膜,于Gerota筋膜与肾周脂肪囊问的疏松纤维组织间进行游离.在肾脏外周数个相对无血管平面间进行分离、切割,完整切除肾脏、肾周脂肪囊. 结果后腹腔镜下根治性肾切除术和单纯肾切除术平均手术时间(132±48)min,肾盂癌和输尿管癌平均手术时间(245±62)min.失血量中位值100(10～2500)ml,术后引流量中位值150(0～1152)ml.输血15例(3.70%),输血量中位值400(400～1650)ml.中转开放4例(0.99%),黏连严重2例,肾蒂暴露困难及出血各1例.平均拔管时间(3.9±1.8)d,术后平均进食时间(2.7±1.2)d,术后平均住院日(8.6±3.8)d. 结论后腹腔镜下解剖性肾切除术利用后腹腔镜下的放大优势,在肾脏周围的数个相对无血管平面进行游离,解剖层次清楚,符合外科原则,手术时间短,出血量较少,术后引流量较少,是后腹腔镜下肾切除的首选术式和发展方向.     

后腹腔镜下根治性肾切除术及其应用解剖学研究

目的 总结后腹腔镜下根治性肾切除术,并对镜下肾周区域相关解剖结构进行研究.方法 2006年1月至2008年3月行后腹腔镜下根治性肾切除术85例.肿瘤位于左肾38例,右肾47例;肿瘤直径2.5～10.5 cm,平均(5.5±1.7)cm;T1N0Mo 74例,T2:N0M0 11例.根据肾筋膜外切除原则,在"两个间隙、上下两极间"分离切除患肾,腹侧为肾旁前间隙(后腹膜与肾前筋膜之间),背侧为腰肌前间隙(肾后筋膜与腰肌筋膜之间),上极达膈下,下方到髂窝.术中辨认重要的解剖结构:后腹膜及其返折、肾前筋膜、侧锥筋膜、肾后筋膜、腰大肌及重要血管. 结果 除1例因与周围粘连严重中转开放手术外,其余均获得成功.手术时间50～165 min,中位数65 min.估计失血量25～600ml,中位数58 ml.术中腹膜破裂5例,肾蒂周围小血管损伤出血6例,无重要脏器及大血管损伤.术后平均随访10(2～25)个月,均无瘤生存,无局部复发或发生穿刺通道种植转移. 结论 后腹腔镜下根治性肾切除术时,熟悉重要的镜下解剖结构有利于提高手术安全性、减少副损伤.     

后腹腔镜解剖性肾上腺肿瘤切除术的治疗体会:附46例报告

目的 探讨后腹腔镜下肾上腺手术解剖定位的方法及临床应用价值.方法 对2009年9月至2011年11月本院所收46例肾上腺肿瘤患者施行后腹腔镜下切除术,其中无功能腺瘤17例,原发性醛固酮增多症13例,皮质醇增多症12例,嗜铬细胞瘤4例.常规制备后腹腔操作空间,打开Gerota筋膜,转向后壁沿腰大肌向上分离至项壁膈肌,分离前壁腹膜肾筋膜与脂肪囊间隙,沿肾上极平面横断分离寻找肾上腺,根据术中情况行肾上腺肿瘤切除或全切除术.结果 46例均成功施行腹腔镜下切除,其中1例因与下腔静脉粘连严重而部分旷置,平均手术时间83±21 min,平均出血量42±15 ml.1例(2.1％)术中胸膜穿孔,1例(2.1％)损伤下腔静脉,均在腹腔镜下完成修补.平均术后住院时间5.2 d,随访3 ～27个月,无远期并发症,46例良性肿瘤未见复发.结论 沿着正确的解剖平面寻找分离肾上腺具有快速、出血少、定位准确的优点,后腹腔镜下肾上腺手术安全、创伤小、恢复快,应为肾上腺手术的首选方法.     

肾周筋膜层面解剖与后腹腔镜解剖性肾筋膜外肾切除术的临床研究：附12例报告（附视频）

目的研究腹膜后筋膜间隙分层及其在腹腔镜下肾切除术中的应用,探讨后腹腔镜下筋膜外肾切除术的疗效。方法 2010年1月至2010年10月我们选择肾前融合筋膜肾筋膜间隙作为肾前方的手术平面,腰肌前间隙作为肾后方的手术平面,行后腹腔镜下筋膜外解剖性肾切除术12例,对临床资料、影像资料和手术录像等进行分析。结果所有病例均手术成功,平均手术时间90±35min,平均术中出血量60±12ml。术中未出现大出血和周围脏器损伤等并发症。术后平均24h下床活动,术后平均住院日6d。结论后腹腔镜下筋膜外解剖性肾切除术具有解剖层次清晰,容易游离,术中出血少,手术时间短,并发症少和安全有效等优点。肾前融合筋膜肾筋膜间隙可作为肾前方手术平面,腰肌前间隙可作为肾后方手术平面。     

腹腔镜肾上腺解剖学与手术入路研究

目的:借助腹腔镜进行肾上腺解剖学研究并建立合理的手术入路。方法:1999年10月至2009年3月我院共行腹膜后腹腔镜肾上腺手术45例;左侧27例,右侧18例。术前拍摄CT和/或MRI,术中摄取录相,术中、术后反复观察肾上腺的解剖部位、层面、周围筋膜、与肾筋膜腔关系等,并设计合理的手术入路。结果:肾前融合筋膜、腰肌筋膜、侧锥筋膜围成肾周间隙。肾周间隙又可再分为肾上腺间隙和肾筋膜间隙两部分。肾筋膜间隙由肾筋膜前后叶环形包绕而成,容纳肾脏、肾周脂肪和肾盂输尿管鞘。肾上腺间隙的前侧边是肾前融合筋膜,外侧边是肾筋膜,内侧边是膈肌脚。肾上腺间隙内包含肾上腺和肾上腺周围脂肪。结论:肾上腺位于肾筋膜腔外,术中沿肾脂肪囊外平面可迅速到达肾上腺。     

后腹膜返折韧带在后腹腔镜根治性肾切除术中的应用价值

目的探讨后腹腔镜根治性肾切除术中以后腹膜返折韧带作为解剖标志进入肾旁前间隙随患肾切除肾前筋膜的临床可行性及意义。 方法回顾性分析2016年3月至2018年3月期间60例行后腹腔镜根治性肾切除术患者的临床资料,男38例,女22例,平均年龄46岁,肿瘤直径3.8～8.4 cm,平均5.6 cm。术中以后腹膜返折韧带为解剖标志开始手术,第一步进入肾旁前间隙,将肾前筋膜随患肾一并切除。 结果本组60例均顺利完成,将肾前筋膜随患肾切除。平均手术时间55 min,平均术中出血量30 ml,平均下床活动时间15 h,平均术后住院天数6 d。56例患者术后随访6～24个月,平均9个月,均无肿瘤复发。 结论在后腹腔镜根治性肾切除术中,选择后腹膜返折韧带作为解剖标志,可有效辨认后腹膜返折与侧锥筋膜的界限,据此开始手术的第一步,更易分离进入肾旁前间隙随患肾一并切除肾前筋膜,达到该术式要求的在肾周筋膜外游离肾脏的标准,值得在临床推广使用。     

腹腔镜经腹膜后解剖性肾上腺(腺瘤)切除术的体会

目的:探讨腹腔镜经腹膜后解剖性肾上腺(腺瘤)切除术的手术方法及临床效果。方法:为48例患者按既定手术步骤施行解剖性肾上腺(腺瘤)切除术。制备腹膜后腔操作空间后,先将肾上极腹膜外脂肪向下推至髂窝,然后避开腹膜返折纵行切开肾后筋膜外层,进入肾周筋膜固有间隙,扩大腹膜后腔,并在此间隙快速找到肾上腺,根据术前诊断及术中情况选择行肾上腺或腺瘤切除术。结果:48例手术均获成功,术中出血少,均未输血,无严重并发症发生。术后住院4～8 d,平均5.2 d。结论:腹腔镜经腹膜后解剖性肾上腺(腺瘤)切除术步骤明确,解剖层次清晰,疗效确切,为肾上腺疾病的微创外科治疗提供了更安全的选择。     

后腹腔镜根治性肾切除术肾蒂血管的处理(附36例报告)

目的探讨后腹腔镜根治性肾切除术肾蒂血管的处理及并发症的预防。方法 2009年1月至2013年12月行后腹腔镜下根治性肾切除术36例。肿瘤位于左肾15例,右肾21例;肿瘤直径3.1~8.8cm,平均(5.8±3.2)cm;其中TlN0M020例,TlN0M016例。术中仔细辨认重要的解剖结构、腹膜返折、侧锥筋膜、腰大肌及重要血管。以膈肌脚和弓状韧带为标志找到肾蒂血管,以Hem-o-lok或endo-cut离断肾蒂血管。结果 36例手术均获得成功。手术时间90~210分钟,中位数118分钟。估计失血量50~650m1,中位数95 ml。术中腹膜破裂8例,肾静脉损伤出血1例,无重要脏器损伤,无中转手术病例。术后平均随访18(2~48)个月,无局部复发或发生穿刺通道种植转移。结论应用后腹壁的肌肉和韧带在后腹腔镜下的形态特点及其与肾脏的毗邻关系来定位肾脏、解剖分离肾门和分离肾血管更安全、更便捷,有利于提高手术的成功率。     

后腹腔镜下肾蒂解剖定位的临床研究

目的 探讨后腹腔镜下肾蒂解剖定位的特征及临床应用价值。 方法 回顾性分析2007年7月至2009年9月行后腹腔镜下肾切除术患者278例的影像学和手术视频资料。男148例,女130例。年龄(54.7±16.5)岁。其中,T1 N0 M0期肾癌117例,T2N0M0期肾癌59例,上尿路上皮癌36例,无功能肾66例。病变位于左肾132例,右肾146例。术中在腰肌前间隙内以腰大肌和膈肌内侧弓状韧带为解剖标志寻找肾蒂。记录寻找肾蒂时间、手术时间、术中估计出血量、恢复饮食时间、下床活动时间、术后住院日、并发症发生率等。 结果 278例手术均成功,无中转开放及输血病例。寻找肾蒂时间(3.5±1.3) min、手术时间(95.6 ±23.8) min,术中估计失血量(72.4±27.5) ml,恢复饮食时间(2.1±0.7)d,下床活动时间(1.8±0.9)d,术后住院日(8.5±2.7)d。 结论 后腹腔镜下肾切除术寻找肾蒂的最佳解剖层面是腰肌前间隙;肾蒂的确切位置为腰大肌与下腔静脉（腹主动脉）间隙内,膈肌内侧弓状韧带下方约2 ～4 cm处。熟悉后腹腔镜下肾蒂的解剖定位特征可以缩短寻找肾蒂时间,减少手术创伤。     

后腹腔镜肾癌根治术中保留肾上腺处置策略的研究

目的:复习后腹腔镜下肾及肾上腺关系的应用解剖,探讨后腹腔镜肾癌根治术中保留肾上腺的处置策略。方法:2009年6月至2012年4月收治105例局限性肾癌患者,其中左侧48例,右侧57例;肿瘤最大径1.5～7.5 cm,平均4.3 cm。均根据以下策略保留肾上腺:(1)经后腹腔途径处理肾蒂血管后,于肾门区域内侧、肾上腺下方游离至肾前筋膜内侧,抬高肾上极,使其具有一定张力,于肾脏后上方游离肾上腺底部,至肾上极内上方,使两者分离;(2)进一步向肾脏上极内侧游离至肾前筋膜内侧,使肾上腺与肾周脂肪完全脱离。结果:105例手术均获成功,无一例中转开放手术。手术时间31～80 min,平均43 min;出血量10～150 ml,平均30 ml;术后3～7 d出院。术中3例发生肾上腺外侧支稍撕裂。结论:根据后腹腔镜下肾及肾上腺的解剖特点,此处置策略使手术操作更加直接,暴露良好,受肾上极弧度及肾周脂肪干扰小;分离肾上腺后稍加推进,即可使肾上腺与肾周脂肪完全脱离,使肾上极的游离更加简便、省时,撕裂肾上腺的几率降低。     

Adrenalektomie im Rahmen der Tumornephrektomie?

In urology, renal cell carcinoma is the third most frequently diagnosed malignancy. Localized, non-metastatic tumors are generally cured by radical tumor nephrectomy. Since the 1960s, this procedure has routinely included removal of the kidney together with the perirenal fat, Gerota's fascia, and ipsilateral adrenal gland. In recent years, improved diagnostic methods have led to the detection of tumors at earlier stages. These methods widen the scope for organ-sparing surgical strategies and have consequently sparked controversy over adrenal gland removal. Despite this, radical tumor nephrectomy that includes adrenal gland removal is still strongly advocated. This is the only suitable surgical approach for the cure of patients with direct tumor infiltration of the adrenal gland. In the case of adrenal involvement, minimal tumor dimension and the predisposing localization of the primary tumor have to relevance. The imaging procedure for diagnosis is also difficult to assess, especially in slim patients with upper role tumors. Finally, to date, no justifiable disadvantages of adrenalectomy have been described.     

Technique of anatomical retroperitoneoscopic adrenalectomy with report of 800 cases

PURPOSE: To our knowledge we introduce the technique of anatomical retroperitoneoscopic adrenalectomy. MATERIALS AND METHODS: From February 2000 to October 2005 anatomical retroperitoneoscopic adrenalectomy was performed in 800 consecutive patients with adrenal lesions using a 3 port lateral retroperitoneal approach. After incising Gerota's fascia 3 relatively bloodless planes were entered consecutively to expose and separate the adrenal gland. When entering the first dissection plane between the perirenal fat and anterior renal fascia located at the superomedial side of the kidney, the adrenal could be identified at the initial stage of the operation. The following dissections proceeded in the plane between the posterior renal fascia and the lateral aspect of perirenal fat, and then in the avascular plane located on the parenchymal surface of the upper renal pole. The adrenal vein was dealt with at the final stage. Operative time was defined as the time from skin incision to skin closure. RESULTS: Mean +/- SE operative time was 45 +/- 19.1 minutes (range 25 to 230) and mean estimated blood loss was 25 +/- 10.6 ml (range 5 to 200). Average time to oral intake and ambulation were 1.2 and 1.0 day, respectively. Minor postoperative complications occurred in 12 patients (1.5%). Major complications and perioperative mortality were not observed. The procedures resulted in marked clinical improvements in patients with a hormone secreting tumor, except in 6 with idiopathic adrenal hyperplasia. CONCLUSIONS: Anatomical retroperitoneoscopic adrenalectomy is a safe, effective, technically efficient procedure for surgical adrenal diseases.     

Translumbar radical nephrectomy of renal cell carcinoma

We invented a new surgical approach to the kidney through the flank to perform a radical nephrectomy for renal cell carcinoma. With the patient in usual lateral decubitus position keeping the dorsum vertical to the operating table, a skin incision is made over the XII rib from the posterior axillary line to the lateral edge of the rectus muscle. After the tip of XII rib is resected by about 5 cm, the retroperitoneal space is entered. Blunt dissection of the posterior aspect of Gerota's fascia from fasciae of the quadratus lumborum and psoas muscle is easily carried out with a liver retractor or intestinal spatula. The pulsating renal artery can be identified through Gerota's fascia when the renal hilus is exposed. Following ligation and division of the artery, renal vein is exposed. On the left side, adrenal, gonadal and occasionally lumbar veins are also ligated and severed in addition to the renal vein. Then, the kidney in Gerota's fascia is removed en bloc with perinephric adipose tissue and adrenal gland. Of 21 patients with renal cell carcinoma seen during 1 year and 3 months from June 1987, 11 underwent this operation, and other 10 patients transperitoneal radical nephrectomy because of the possible tumor extension into the renal vein, inferior vena cava or adjacent organ, the severe spinal deformity or metastases and the necessity of additional surgical procedures for concomitant benign intraperitoneal diseases. The blood loss was smaller and operating time was shorter significantly in the translumbar group than the evaluable transperitoneal group. None of those in the translumbar group received blood transfusion. As complications, pneumothorax due to pleural injury during operation and postoperative incisional hernia occurred each in one patient, but no other serious one was found. From the above results, this approach seems to be one of choices for the surgical treatment of renal cell carcinoma, as long as the tumor is not likely to extend to adjacent organs, ipsilateral nodes or the inferior vena cava.     

Anatomic considerations in extraperitoneal approach to radical nephrectomy

The interrelationship between the lateral and posterior portions of the peritoneum and Gerota's fascia allows them to be separated from each other, permitting ready visualization of the major renal vessels. The posterior relationship between Gerota's fascia and the transversalis fascia overlying the more posterior psoas muscle can be used to advantage in exposing the renal vessels posteriorly. That the fascial layers defining the retroperitoneal spaces might therefore be used in dissecting the renal hilum and vessels in the performance of radical nephrectomy prompted the present investigation. Twenty patients underwent this approach for radical nephrectomy for varying stages of renal cell carcinoma involving either upper, mid, or lower portion of right or left kidney. Postoperative recovery appeared to be shortened because of the lesser interval of ileus than had previously been encountered using a transperitoneal approach. Despite the minimal manipulation of the kidney prior to ligation of the renal vessels, there was no apparent increased tumor dissemination as detected clinically, and experimentally there appeared to be no increase in tumor cells in the venous effluent. Operative time, blood loss, and postoperative complications were comparable to those reported for the transperitoneal approach. This means of performing radical nephrectomy, based on the relationship of fascial layers in the retroperitoneum thus appeared to lend itself to easier dissection as well as lesser postoperative ileus and corresponding shorter hospital stays.     

根治性肾切除术治疗肾癌是否需要常规切除同侧肾上腺

目的 探讨根治性肾切除时是否需要常规切除同侧肾上腺.方法 分析263例肾癌患者的临床资料.比较同侧肾上腺切除组与保留组手术时间、出血量、手术并发症以及生存率有无差异(t检验);分析肾上腺受侵患者的临床特点.生存分析采用Kaplan-Meier法,组间差异采用longrank检验.结果 临床分期T_(1～2)N_0M_0 214例,T_(3～4)N_(0～2)M_0 26例,T_(1～4)N_(0～2)M_1 23例.根治性肾切除术时切除同侧肾上腺146例,保留同侧肾上腺117例.同侧肾上腺切除组与保留组手术时间、出血量、手术并发症比较差异均无统计学意义(P＞0.05).术后病理证实肾肿瘤侵及同侧肾上腺8例,其肾原发肿瘤最大径平均为9.7 cm,肿瘤最大径≥8 cm 5例,肿瘤位于肾上极6例,累及全肾2例.临床分期为Ⅰ期或Ⅱ期者切除同侧肾上腺129例,病理结果证实同侧肾上腺受侵仅4例(3.1%);Ⅲ期或Ⅳ期患者切除同侧肾上腺17例,病理证实同侧肾上腺受侵4例(23.5%).随访3～102个月,平均28个月.同侧肾上腺切除组与保留组按各病理分期比较生存率差异均无统计学意义.结论 肿瘤直径≥8 cm、位于肾上极或累及全肾、临床分期≥Ⅲ期均是肾癌侵及肾上腺的危险因素,此类患者行根治性肾切除术时应切除同侧肾上腺,其余早期肾癌患者实施手术治疗时可以保留同侧肾上腺.     

Renal trauma and retroperitoneal hematomas-indications for exploration.

One hundred nineteen patients with renal trauma documented at laparotomy or by an abnormal excretory urogram were followed up sufficiently to allow assessment of their postinjury course. One-fourth of these patients had a laparotomy and Gerota's fascia was opened; one-fourth had a laparotomy and Gerota's fascia was not opened; and one-half had no laparotomy. Gerota's fascia was opened only after vascular control of the renal pedicle was obtained. Nonetheless, the loss of renal tissue in this group was high. Twenty-three of 34 patients (68%) required nephrectomy or partial nephrectomy, indicating the severity of their renal injuries. The loss of renal tissue was low in the two groups in which Gerota's fascia was not opened. Six of 85 patients (7%) developed complications eventually requiring nephrectomy or partial nephrectomy; an additional three patients (4%) demonstrated loss of renal tissue on followup urograms, the loss being minimal in all three cases. The relatively low morbidity in these 85 patients indicates that their original renal injuries were, for the most part, less serious than the injuries in the group in which Gerota's fascia was opened. This low morbidity also indicates that retroperitoneal hematomas in the area of the kidney which are nonexpanding, contained, and nonpulsatile need not be routinely explored.     

Absence of Gerota's fascia in pelvic ectopic kidney: implications in laparoscopic radical nephrectomy

We report the anatomic alterations in pelvic ectopic kidney and its bearing on the performance of laparoscopic radical nephrectomy (LRN) and its likely effect on the ultimate oncologic outcome. A patient with Stage T2N0M0 renal tumor in a pelvic kidney underwent transperitoneal LRN. LRN was performed by mobilizing the specimen with an adequate amount of perirenal fat, because no distinct Gerota's fascia can be found in the pelvic kidney. At 1 year of follow-up, the patient was free of disease. LRN is a good option for managing localized renal tumor even in the pelvic kidney. The impact of the absence of Gerota's fascia in the pelvic kidney needs further evaluation.