肾蒂旋转法辅助治疗后腹腔镜下腹侧肾肿瘤的肾部分切除术

目的：为降低后腹腔镜入路的腹侧肾部分切除术手术难度，减少手术风险，总结归纳并发展后腹腔镜入路肾部分切除术的肾蒂旋转法及相关技术。方法：总结归纳并发展一整套针对腹侧肾门区肾肿瘤的肾蒂旋转法操作技术，包括肾蒂旋转、双层缝合、早期开放动脉等。该技术有助于实施后腹腔入路的肾部分切除术，手术效果的评价由手术时间、热缺血时间、术中出血量、手术切缘、术后肾功能、手术并发症等组成。本研究回顾性分析中南大学湘雅医院28例腹侧肾肿瘤患者资料，其中15例为较复杂的肾门区肿瘤。结果：平均肿瘤大小为（3.8±0.5） cm，平均R.E.N.A.L评分为8（范围7~9）。手术中平均热缺血时间（23.8±4.7） min，缝合时间（26.2±6.5） min，估计失血量（139.1±54.0） mL，手术时间（124.1±12.1） min，中位住院天数为4 d。7例患者出现Clavien Dindo Ⅰ~Ⅱ级并发症,所有患者病理检查均示切缘阴性,中位随访7个月无局部复发或远处转移。结论：对于腹侧肾肿瘤，尤其是位于肾门区的肾肿瘤，利用肾蒂旋转法行后腹腔镜下肾部分切除术是安全有效的；短时间随访结果较乐观，但需长时间随访。

Retroperitoneal laparoscopic with renal pedicle rotation for partial nephrectomy of ventro-renal tumor

Objective: Retro-laparoscopic partial nephrectomy is a challenge for ventro-renal tumors, especially hilar tumors.The tumors are partial or entirely out of operative field and there is blind space for operation.To solve this problem, a set of techniques including renal pedicle rotation is developed.Methods: A set of techniques including renal pedicle rotation, double-layer suture, early artery unclamping for retro-laparoscopic nephrectomy for ventro-renal tumors, especially hilar tumors were developed.Hilar tumors were located anteriorly to the angle of the renal and renal arteries and in contact with the anterior surface of the renal artery.The evaluation of the outcomes included the operation time, warm ischemia time, estimated haemorrhage, surgical margin, renal function after operation, and complications.This study reviewed the data of 28 patients with ventro-renal tumor, including 15 patients with complex hilar tumors.Results: The average tumor size was (3.8±0.5) cm.The average R.E.N.A.L score was 8 (ranging from 7 to 9).The average warm ischemia time was (23.8±4.7) min, and suture time was (26.2±6.5) min, and operation time was (124.1±12.1) min.The median hospital stay was 4 days and the average estimated haemorrhage was (139.1±54.0) mL.All the surgeries were operated under laparoscope and no surgery switched to open surgery.Seven patients developed Clavien Dindo Ⅰ-Ⅱ complications after operation.Three patients (10.7%) developed collective system damage and received repair of collective system in time and three patients (10.7%) developed slightly gross hematuria (Clavien-DindoⅠ).Two patients developed wound infection (Clavien-DindⅡ).Three patients (10.7%) got renal vein clamped because of capillary hemorrhage from basilar part of tumors.There were 14 patients received early unclamping of renal artery, and no obvious renal vessel damage was found.There were statistically significant differences between the serum creatinine levels (P<0.05) and the estimated glomerular filtration rates (P=0.02) before and after surgery.All the patients'' serum creatinine levels were in normal range and no patient needed regular dialysis.There was no positive surgical margin and the median follow-up was 7 months without local recurrence or distant metastasis.Conclusion: It is safe and effective to apply renal pedicle rotation technique in retro-laparoscopic partial nephrectomy for ventro-renal tumors.The short-term follow-up results are optimistic, but long follow-up is required.