腹腔镜保留肾单位手术的实验与临床研究

目的 探讨腹腔镜保留肾单位手术的可行性及疗效。方法 成功完成2例家猪腹腔镜肾部分切除术后，于2002年11月至2004年3月，行经腹途径腹腔镜保留肾单位手术8例（肾肿瘤剜除术3例，肾部分切除术5例）。男女各4例，平均年龄43岁。肾细胞癌5例，肾错构瘤3例。肿瘤直径2．0～3．8cm，平均2．6cm。左侧3例，右侧5例。术中采用血管束带实行瘤区肾实质血流阻断结合肾动脉阻断。创面止血结合采用电凝、超声刀、止血纱布、生物蛋白胶及镜下直接缝合技术。结果 8例手术均获成功。手术时间130～235min，平均165min。术中出血80～600ml，平均240ml。区域性肾实质血流阻断时间0～30min，平均18min。肾动脉阻断时间0～20min，平均14min。术后住院5～9d，平均7d。术中发生瘤体裂开1例，术后发生应激性溃疡1例。术后随访3～19个月，平均10个月，未见患肾功能损害和肿瘤复发或转移。结论 对于严格选择的肾脏小肿瘤病例，腹腔镜保留肾单位手术是一种安全可行的治疗选择。区域性肾实质血流阻断法，能缩短肾动脉阻断时间，减少患肾功能热缺血损害。熟练掌握镜下直接缝合技术是保证本术式成功的关键。

Experimental study and clinical application of transperitoneal laparoscopic nephron-sparing surgery

Objective To evaluate the feasibility and clinical effect of laparoscopic nephron-sparing surgery ( LNSS) in the treatment of small reral tumors. Methods On the basis of successful performance of laparoscopic partial nephrectomy in 2 pig models, we accomplished 8 cases of transperitoneal LNSS (tumor enucleation in 3 and partial nephrectomy in (?)) from November 2002 to March 2004. Of the 8 patients (4 males and 4 females with a mean age of 43 ears) ,5 had renal cell carcinoma and 3 had hamartoma. The mean tumor diameter was 2. 6cm (range,2.0-3. 8cm). Three tumors were located at the left and 5 at the right kidney. Our laparoscopic technique involved utilizing a plastic cable tie to achieve local parenchymal compression and ischemia, and transient clamping of the renal artery. Hemostasis was achieved with combined use of electrocautery,ultrasonic scalpel,gelatin sponges,fibrin glue and free hand intracorporeal laparoscopic suturing and knot tying. Results All procedures were successfully completed without conversion to open surgery. The mean operative time was 65 min (range, 130 -235 min) and mean blood loss was 240 ml ( range,80 -600 ml). The mean local paienchymal ischemia time using cable tie compression was 18 min ( range,0 - 30 min). The mean renal artery clamping time was 14 min ( range,0 - 20 min). All patients with renal cell carcinoma had negative surgical margins. The hospital stay averaged 7 d (range, 5 -9 d). Major complications occurred in 2 patients,i(?)cluding intraoperative splitting of the tumor in 1 and postoperative gastric ulcer in 1. During a mean follow - up of 10 months (range,3 - 19 months) no patient had renal functional damage and recurrence or metastasis. Conclusions LNSS is a feasible and safe alternative for strictly selected patients with small renal tumor. Using cable tie to compress renal parenchyma makes it possible to reduce the time of renal artery clamping and thus to protect the kidney from ischemic damage. This method also provides sufficient surgical manipulating time. Hemostasis can be achieved by combined use of several methods or materials and the skilled intracorporeal suturing and knot tying is the key to successful LNSS.