完全腹腔镜下主-双股动脉旁路术治疗主、髂动脉硬化闭塞症

目的探讨完全腹腔镜下主一双股动脉旁路术治疗主、髂动脉硬化闭塞症的安全性和可行性。方法2008年11月～2012年11月，完全腹腔镜下主一双股动脉旁路术连续治疗7例主、髂动脉硬化闭塞症。7例均为男性，年龄52—70岁，平均60．6岁。Rutherford分级3级5例，4级I例，5级1例。主、髂病变TASC分级C级2例，D级5例。全麻，先用完全腹腔镜技术经左侧结肠后肾后入路游离肾下腹主动脉，再将“Y”形涤纶人工血管近端与之行端侧吻合，人工血管远端经腹膜后隧道引出至相应侧腹股沟，直视下分别与双侧股动脉吻合。结果5例顺利完成腹腔镜下主一双股动脉旁路术，2例中转开腹（肠系膜下动脉断端的钛夹脱落出血1例，结肠损伤1例）。手术时间420～840rain（中位数585min），主动脉吻合时间40～150min（中位数65rain），术中出血量400—1500ml（中位数800m1）。未中转的5例均在术后12—40h恢复进食，术后顺利康复出院。结肠损伤患者术后结肠漏二次开腹手术，结肠漏治愈，术后46天死于呼吸衰竭。一过性左肾积水1例，治愈。吻合口近端腹主动脉残留重度狭窄1例行支架治疗治愈。无症状的部分左肾梗死1例。6例随访2—51个月，平均11．2月，均健在，超声随访移植物均通畅，静息痛和间歇跛行症状均消失。结论完全腹腔镜下主一双股动脉旁路术治疗主、髂动脉硬化闭塞症是安全、可行的。在学习曲线中及时中转保证手术安全是必要的。

Total Laparoscopic Aortobifemoral Bypass for Aortoiliac Occlusive Disease

Objective To evaluate the safety and feasibility of total laparoscopic aortobifemoral bypass surgery for aortoiliac occlusive disease （AIOD）. Methods From November 2008 to November 2012, 7 patients of severe AIOD underwent total laparoscopic aortobifemoral bypass in our hospital. The 7 patients were all male, with a mean age of 60. 6 （ range, 52 - 70 ）. Rutherford classification： 5 cases were class 3, 1 case was class 4 and 1 case was class 5. TASC classification of lesion： 2 cases were TASC C and 5 cases were TASC D. Under general anesthesia with a total laparoscopic technique, the infrarenal aorta was exposed by a transperitoneal left retrocolic retrorenal approach, and end-to-side aorta-prosthesis anastomosis was done to a Y-shaped Preclotted Dacron graft, then the two prosthetic limbs were pulled out retroperitoneally to the ipsilateral groin, prosthesis-femoral artery anastomoses were performed with open technique. Results Five operations were performed successfully, and 2 cases were converted to open surgery （ 1 case of bleeding caused by titanium clip at inferior mesenteric artery, 1 case of colonic injury）. Median operation time was 585 min （range, 420 -840 min） ; median blood loss was 800 ml （range, 400 - 1500 ml） ; median aortic anastomosis time was 65 min （ range, 40 - 150 min）. The 5 successful cases resumed diet 12 to 40 h after the surgery and recovered soon. The patient suffering from colonic injury underwent a second open surgery and died 46 d after the surgery due to respiratory failure. One patient suffering from transient hydronephrosis recovered after treatment. Two patients who suffered juxtarenal aortoiliac occlusion underwent Fogarty catheter thromboembolectomy during laparoscopic surgery ： one had an aortic residual stenosis proximal to anastomosis site, and restored after endovascular stenting on 12th day postoperatively, the other had a small partial asymptomatic left renal infarction which was found by enhanced CT. Six cases were followed up for 2 to 51 months （ average, 11.2 months） and M1 were alive. Ultrasound examination revealed that all the grafts were unobstructed. Symptoms like rest pain and intermittent elaudication all disappeared. Conclusions Total laparoscopic aortobifemoral bypass surgery is a safe and feasible procedure for the treatment of AIOD. Conversion in time is prerequisite for ensuring the safety of the surgery.