内侧入路清扫胰上淋巴结在腹腔镜胃癌根治术中的应用价值

目的:探讨内侧入路清扫胰上淋巴结在腹腔镜胃癌根治术中的应用价值。方法:选择2016年1月至2018年6月在我院行腹腔镜手术的104例远端胃癌患者作为研究对象，采用随机数字表法将患者分为对照组和观察组各52例。对照组采用常规入路清扫胰上淋巴结，观察组采用内侧入路清扫胰上淋巴结。观察2组患者手术时间、术中出血量、术后并发症（包括吻合口狭窄、胰瘘、腹腔脓肿，医院死亡率）、术后住院时间。结果:2组手术时间、输血率、中转手术率相比较差异均无统计学意义（P>0.05）；2组术中失血量、吻合类型、体内吻合率、胰上淋巴结清扫数量等存在差异（P<0.05）。观察组并发症发生率低于对照组，但差异无统计学意义（P>0.05）。2组下地时间和院内死亡率相比较差异无统计学意义（P>0.05），观察组经口进食时间、住院时间均低于对照组，差异均有统计学意义（P<0.05）。结论:腹腔镜胃癌根治术中采用内侧入路清扫胰上淋巴结可提高淋巴结清扫数，促进术后恢复，值得进一步研究探讨。     

完全腹腔镜胃癌根治术消化道重建的方法与技巧

腹腔镜手术视野清、切口小,患者术后切口疼痛轻,切口感染、裂开等相关并发症发生率低,术后恢复快,术后住院日缩短.目前,腹腔镜手术不仅用于治疗胆囊切除、脾脏切除等器官的良性病变,已开始用于肝脏和胰腺等富血供实质性器官,甚至胃肠道恶性肿瘤的根治性切除. 超声刀等器械解决了腹腔镜下切割止血和解剖分离等外科手术基本操作问题,可在胃周血管根部离断血管并清扫相应的淋巴结群,完成胃癌根治性切除.目前绝大多数术者仅在腹腔镜直视下完成淋巴结清扫,然后通过上腹部辅助小切口完成胃切除和消化道重建.确切地说,这种术式应称为腹腔镜辅助胃癌根治术( laparoscopy-assisted gastrectomy,LAG).     

腹腔镜辅助胃癌D2根治术淋巴结清扫的早期体会

目的 分析腹腔镜辅助胃癌D2根治术清扫血管根部各组淋巴结所需时间,探讨各组淋巴结清扫的难点和手术技巧.方法 采用观看手术录像方法,计算2010年10月至2011年7月于中山大学肿瘤防治中心施行的25例腹腔镜辅助胃癌D2根治术,分别计算清扫胃网膜左、胃网膜右、胃右及胃左血管根部淋巴结群所需时间,并比较各组淋巴结清扫所需时...     

腹腔镜胃癌根治术与开放性胃癌根治术的对比研究

目的　通过比较腹腔镜下胃癌根治术与开放性胃癌根治术的差异，探讨腹腔镜下胃癌根治性的可行性。方法 选取２００８年５月至２００９年１０月行腹腔镜下胃癌根治性切除术８１例，其中根治性远端胃癌根治术４８例，根治性近端胃癌根治术１９例，根治性全胃切除术１４例，与开放性胃癌根治术（相同分期）８０例的病例资料作回顾性分析。结果　８１例均在腹腔镜辅助下完成手术，Ｄ１淋巴结清扫６例，Ｄ２淋巴结清扫７５例。腹腔镜手术和开放性手术的平均手术时间分别为２５８ｍｉｎ和１９３ｍｉｎ（Ｐ＜０.０５），术中平均出血量分别为２９２ｍｌ和３８９ｍｌ（Ｐ＜０.０５），清扫淋巴结平均数分别为１６.５枚和１７.８枚（Ｐ＞０.０５）；术后平均胃肠功能恢复时间分别为２.９天和３.９天（Ｐ＜０.０５）；腹腔镜手术组术中无脏器损伤，术后无出血、吻合口漏及肺部感染等并发症，无手术死亡病例。结论　腹腔镜下胃癌根治术安全、可行，与开放性胃癌根治术具有相同的淋巴结清扫范围。     

腹腔镜下中间入路与侧方入路右半结肠癌根治术的术中、术后情况比较

目的:探讨腹腔镜下中间入路右半结肠癌根治术的临床疗效及并发症。方法:回顾性分析在2015年6月1日至2018年6月1日期间由中国人民解放军第967医院普外科收治的82例右半结肠癌患者临床资料，45例患者接受腹腔镜中间入路右半结肠癌根治术，为中间入路组，37例患者接受腹腔镜侧方入路右半结肠癌根治术，为侧方入路组；对比两组患者手术时间、术中出血量、清扫淋巴结数量、中转开腹率、术后肠功能恢复时间、术后住院时间及术后并发症等临床指标，评价分析腹腔镜下中间入路右半结肠癌根治术的优越性。结果:中间入路组手术时间、术中出血量、淋巴结清扫数量、中转开腹率与侧方入路组相比差异显著，均有统计学意义（P＜0.05）；但中间入路组在术后肠功能恢复时间、术后住院时间及术后并发症发生情况等方面与侧方入路组相比无统计学差异（P＞0.05）。结论:采用腹腔镜下中间入路右半结肠癌根治术能缩短手术时间、减少术中出血量、减少中转开腹率、增加清扫淋巴结个数，近期治疗效果满意，值得在临床中应用并推广。     

腹腔镜根治性全胃切除术

腹腔镜胃癌根治术较传统手术有以下优势：具有创伤小、术后恢复快、美观等微创优势;对病人免疫功能影响小;超声刀的良好凝固作用能减少淋巴结清扫过程中肿瘤细胞自淋巴管脱落。目前已经证实腹腔镜胃恶性肿瘤手术适应证包括：①胃癌肿瘤浸润深度在T3以内;②胃恶性间质瘤、淋巴瘤等其他恶性肿瘤;③胃恶性肿瘤的探查及分期;④晚期胃恶性肿瘤的短路手术;⑤胃癌术前、术中分期检查为Ⅰ、Ⅱ、Ⅲa期。手术步骤包括：腹腔探查;淋巴结清扫（腹腔镜根治性全胃切除D2淋巴结清扫范围包括第1、2、3、4sa、4sb、4d、5、6、7、8a、9、11p、11d、12a、14v 组淋巴结,对于胃上部癌可不行第12a、14v 组淋巴结清扫）;全胃切除;消化道重建。     

腹腔镜辅助远端胃癌D2根治术10例

目的探讨腹腔镜辅助远端胃癌D2根治术可行性。方法回顾分析同一术者,同时期内10例腹腔镜辅助远端胃癌手术的临床资料,观察手术时间、术中出血、淋巴结清扫数量及近期并发症情况。结果 10例患者均顺利完成手术,平均手术时间(283±42)min,术中平均出血量(80±15)ml,均未术中输血,平均清扫淋巴结数目(21.3±9.3)枚,肛门平均排气时间(47.4±8.3)h。术后病理显示所有标本切缘均为阴性。无吻合口瘘、腹腔内出血等术后并发症。结论腹腔镜辅助远端胃癌D2根治术,创伤小,手术安全,近期效果良好。远期效果尚需循证医学证据证实。     

腹腔镜辅助早期胃癌根治术的临床研究（附18例报告）

目的探讨腹腔镜辅助胃癌根治术在早期胃癌中的临床应用。方法回顾性分析2006年5月至2009年12月间接受腹腔镜辅助胃癌根治术的早期胃癌病例的临床资料,包括手术方式、手术时间、术中失血量、排气时间、术后住院时间、术后病理、随访等。结果 18例手术均在腹腔镜辅助下完成,没有中转开腹。其中远端胃切除15例,近端胃切除3例,腹腔镜下D1＋α式淋巴结清扫13例,Dl＋β式淋巴结清扫2例,D2式淋巴结清扫3例。手术时间为（140.5±30.6）分钟,术中失血（120.7±20.2）mL,术后排气时间（3.0±0.5）天,术后住院天数为（9.7±1.2）天;3例（3/18）患者出现并发症,其中腹腔内出血、淋巴漏、切口感染各1例,经手术和非手术治疗后痊愈。标本上、下切缘病理检查均无肿瘤残留,平均清扫淋巴结（13.6±4.0）枚,其中有2例（2/18）发现淋巴结转移。除1例失访外,其余17例随访8-51月,均无肿瘤复发和远处转移。结论腹腔镜辅助胃癌根治术是治疗早期胃癌安全、可行、有效的手术方法。     

胃下部癌D2＋式根治性远端胃切除Billroth－Ⅱ吻合术

目前，对进展期胃癌的根治性手术，尽管在淋巴结清扫范围、血管脉络化层面、网膜囊剥离、消化道重建等诸多方面存在争议。以D2为基础的根治性远端胃切除或全胃切除作为标准术式已被广泛接受。进展期远端胃癌为各部胃癌中最常见者，因此D2或D2＋根治性远端胃切除为最常见的胃癌根治术式。以下图像资料为开腹远端胃癌根治术（D2＋，Billroth－Ⅱ），在遵循囊外剥离、无瘤外科原则的基础上，以血管神经鞘膜为解剖层面，彻底廓清远端胃相关的胃周血管簇及肝十二指肠韧带内淋巴结，并以Billroth－Ⅱ式重建消化道。     

腹腔镜辅助下胃癌D2根治术150例疗效评价

目的探讨腹腔镜辅助下胃癌D2根治术的可行性及疗效。方法回顾分析150例(2010年5月至2014年8月)腹腔镜辅助下胃癌D2根治术(LAG组)以及同期150例传统开腹胃癌手术(OG组)的临床资料。比较两组患者的术中及术后情况、淋巴结清扫数目、并发症发生率等。结果两组手术时间、切口长度、肛门排气时间、鼻饲流质时间、术后住院天数有明显差别(均P<0.05);淋巴结清扫数目、转移数目、术中出血量、消化道重建方式、肿瘤浸润深度、肿瘤与上下切缘距离及肿瘤最大径则无统计学差异(均P>0.05)。结论腹腔镜辅助下胃癌根治术具有安全、术后恢复快等优点,同时在淋巴结清扫方面能达到开腹胃癌手术相同的效果。     

Comments to young surgeons concerning laparoscopic spleen- preserving D2 lymph node dissection for advanced gastric cancer on the upper body

Qualified radical gastrectomy with lymph node dissection is very important to the prognosis of patients with gastric cancer. Now D2 lymph node dissection is standard procedure for gastric cancer surgery, and spleen hilar lymph node dissection is mandatory for gastric cancer in upper body. Because the anatomy of vessels in this area is very complicated, D2 lymph node dissection is technical challenging not only for open gastrectomy but also for laparoscopic one. Adapting a new technique is important to all surgeons, but we surgeons should always consider a patient＇s safety as the most important factor during surgery and that efforts should be based on scientific rationale with oncologic principles. I hope that the recent report by Huang et al. about laparoscopic spleen preserving hilar lymph node dissection would be helpful to young surgeons who will perform laparoscpic total gastrectomy for gastric cancer.     

进展期远端胃癌行扩大淋巴结清扫术的研究进展

淋巴结清扫范围一直是胃癌外科的热点问题。D2根治术作为进展期胃癌标准手术已达成共识,然而扩大淋巴结清扫的价值依然存在争议。进展期远端胃癌第14v组淋巴结转移率较高,D2+14v组淋巴结清扫有可能改善第6组淋巴结明显转移患者预后;尽管胃癌腹主动脉旁淋巴结转移视为M1,但D2+16a2/b1淋巴结清扫对局限性第16组淋巴结转移患者可能获益;而D2+13组淋巴结清扫有可能提高伴有十二指肠浸润胃癌患者生存率。本文旨在探讨扩大淋巴结清扫在胃癌中的价值,以期为临床提供依据,现就进展期远端胃癌扩大淋巴结清扫的研究进展进行综述。      

Is sentinel lymph node navigation useful for laparoscopic gastrectomy

The aim of this paper is to assess the usefulness of sentinel lymph node navigation for laparoscopic gastrectomy. The standard lymph node dissection for gastric cancer is a D2 dissection. D2 dissection and sentinel lymph node biopsy can be performed with laparoscopic gastrectomy as well as with open surgery. Sentinel lymph node navigation surgery for gastric cancer has not yet been established, but once a strong consensus is reached we will be able to perform the laparoscopic gastrectomy safely.     

Comparison of laparoscopy-assisted by conventional open distal gastrectomy and extraperigastric lymph node dissection in early gastric cancer

BACKGROUND AND OBJECTIVES: Laparoscopy-assisted gastrectomy with lymph node dissection for gastric cancer is considered technically more complicated than the open method. Moreover, the safety and efficacy of laparoscopy-assisted distal gastrectomy (LADG) with extraperigastric lymph node dissection in patients with gastric cancer have not been established yet. To evaluate short-term surgical validity, surgical outcome of the laparoscopy-assisted distal gastrectomy (LADG) with extraperigastric lymph node dissection was compared with that of the conventional open distal gastrectomy (CODG) in patients with early gastric cancer. METHODS: One hundred and forty-seven patients with early gastric cancer received radical distal gastrectomy during 2002 and 2003, where LADG was undergone in 71 patients. The clinicopathologic characteristics, postoperative outcomes and courses, and postoperative morbidities and mortalities were compared between the two groups. Data were retrieved from the stomach cancer database at Dong-A University Medical center. RESULTS: Baseline characteristics, including sex, age, body mass index (BMI), American Society of Anesthesiology (ASA) class, tumor size, T stage, and lymph node metastasis were similar between the two groups. No significant differences were found between these groups in terms of the number of retrieved lymph nodes with respect to D1 + alpha (D1 + no. 7) and D1 + beta (D1 + no. 7, 8a, and 9) lymphadenectomy. In the LADG group, wound size was smaller (P < 0.0001), but operation time was longer (P = 0.0001) than in the CODG group. Perioperative recovery was faster in the LADG group than in the CODG group, as reflected by a shorter hospital stay (P = 0.0176) and less times of additional analgesics (P = 0.0370). Serum albumin level in LADG was higher (P = 0.0002) on day 7 than that in CODG, and the leukocyte count in LADG lower (P = 0.0445) on day 1 than that in CODG. Postoperative morbidities and mortalities were not significantly different between the two groups. CONCLUSIONS: Our data confirmed that LADG with extraperigastric (no. 7, 8, and 9) lymph node dissection proved to be feasible and acceptable surgical technique for early gastric cancer. At least taking a surgical point of view, LADG with extraperigastric lymph node dissection is suggested to be a preferred surgical option for patients with early gastric cancer. Its oncologic validity awaits larger and prospective multicenter trials.     

开腹与腹腔镜脾门淋巴结清扫对进展期胃癌的近期疗效观察及生存分析

目的探讨开腹与腹腔镜脾门淋巴结清扫对进展期胃癌的近期疗效及生存情况。方法  选择2017年1月至2019年6月南通市中医院收治的86例拟行根治性全胃切除术的进展期胃癌为研究对象,对照组采用开腹脾门淋巴结清扫,研究组采用腹腔镜脾门淋巴结清扫。比较两组术中、术后情况、术后7 d并发症发生情况及无进展生存时间。结果两组总手术时间、肿瘤大小、No.10淋巴结清扫时间。No.10淋巴结清扫数目、淋巴结总清扫数目比较差异无统计学意义（P＞0.05）,研究组总出血量、清扫No.10淋巴结出血量低于对照组（P＜0.05）;两组引流管拔出时间、住院费用比较差异无统计学意义（P＞0.05）,研究组住院时间、术后首次排便时间、胃管拔出时间、术后首次排气时间均短于对照组（P＜0.05）;两组术后7 d内并发症总发生率比较差异无统计学意义（P＞0.05）;随访3年,对照组失访1例,研究组失访2例,随访率为96.51%,研究组与对照组无进展生存时间分别为22.35个月（95%CI：12.39～28.41）、21.73个月（95%CI：9.25～24.52）,两组无进展生存曲线比较,差异无统计学意义（P＞0.05）。结论在进展期胃癌根治性全胃切除术中,腹腔镜脾门淋巴结清扫近期效果良好,安全可行,且预后良好。     

Advances in Laparoscopic and Robotic Gastrectomy for Gastric Cancer

Robot-assisted gastrectomy has been reported to be a safe alternative to both conventional laparoscopy and the open approach for treating early gastric carcinoma. Currently, there are a limited number of published reports on this technique in the literature. We assessed the current status of robotic and laparoscopic surgery in the treatment of gastric cancer and compared the operative outcomes, learning curves, and oncological outcome of the two approaches. Robotic gastrectomy offers benefits that include increased ease of performing D2 lymph node dissection and reduced blood loss compared with laparoscopic gastrectomy. However, the operative time is longer, and robotic gastrectomy is more costly for the patients. Regarding to the operative and oncological outcomes, there appears to be no significant differences between laparoscopic and robotic gastrectomies after the surgeon overcomes the associated learning curves. Sharing the available knowledge regarding laparoscopic and robotic gastrectomies could shorten these learning curves. For elder patients, minimally invasive surgery that decreases the postoperative recovery time should be considered the preferred treatment. Prospective randomized studies are required to compare the surgical and oncological outcomes among laparoscopic, robotic, and open surgeries for both early and advanced gastric cancer.     

子宫内膜癌淋巴取样术的临床意义

目的：探讨子宫内膜癌盆腔及腹主动脉旁淋巴取样的临床意义。方法：分析1995年1月～2002年12月本院手术治疗的311例子宫内膜癌患者,其中,197例行淋巴取样或淋巴清扫。手术方式根椐手术切除淋巴结情况分为二组。1）取样组,筋膜外全子宫双附件切除/次广泛子宫切除术＋盆腔/腹主动脉旁淋巴结取样术114例;2）清扫组,次广泛/广泛子宫切除术＋盆腔淋巴结清扫/腹主动脉旁淋巴结切除术83例。结果：取样组切除淋巴结中位组数5组,中位切除淋巴结15枚,淋巴结转移8例。清扫组切除淋巴结中位组数8组,中位切除淋巴结27枚,淋巴结转移6例。5年生存率分别为90.2%和90.9%。结论：子宫内膜癌淋巴取样术可准确了解淋巴结转移情况,适宜手术分期,并不影响生存率,是避免过度治疗的方法。     

Laparoscopic radical cystectomy

Open radical cystectomy with lymph node dissection remains the gold standard treatment for recurrent, high-grade, non-muscle-invasive and for muscle-invasive bladder cancer. The excellent perioperative and long-term results provided by laparoscopic surgery and the advances in instrumentation design have naturally paved the way for development of laparoscopic radical cystectomy (LRC). In this review, surgical and long-term oncological outcomes of LRC are analysed. The advantages of this technique compared with open surgery are described. The differences between pure laparoscopic technique or laparoscopic cystectomy and extracorporeal urinary diversion have also been analysed.     

Curettage and aspiration in splenic hilar lymph node dissection for spleen-preserving radical D2 gastrectomy

D2 radical gastrectomy is the standard procedure for gastric cancer in the middle or upper part of the stomach. According to the latest Japanese treatment guidelines for gastric cancer, dissection of the splenic hilar lymph nodes is required during the radical treatment for this condition. This study reports a D2 radical total gastrectomy employing the curettage and dissection techniques, in which the resection of the anterior lobe of transverse mesocolon, vascular denudation and splenic hilar lymph node dissection were successfully completed.Key Words: Gastric cancer, gastrectomy, lymph node dissection, curettage and dissection