经腹膜后与经腹腔入路腹腔镜下侧位肾上腺手术的比较

目的 比较经腹膜后入路和腹腔入路腹腔镜下肾上腺手术的方法、优缺点，总结腹腔镜下肾上腺手术的适应证、禁忌证以及2种入路手术的选择。方法 回顾分析1996年7月-2005年12月105例腹腔镜肾上腺手术经验，其中经腹腔入路50例，经腹膜后入路55例。比较2组患者的手术时间、手术优缺点、中转开放手术率、手术并发症等指标。结果 经腹腔入路者5例（10％）中转开放手术，其中1例因为肝损伤，2例因发生肾上腺血管难以控制的出血，2例因粘连严重镜下难以分离；经腹膜后入路者2例（4％）中转开放手术，其中1例肾损伤，另1例暴露困难。余98例手术均成功。经腹腔入路手术时间50～180min，平均82min；出血量15～180ml，平均65ml；36h即下床活动；术后住院5～14d。经腹膜后途径者手术时间45～130min，平均60min；出血量15～100ml，平均30ml；24h后下床活动；术后住院3～7d。术中并发症：经腹腔途径者1例发生肝损伤，2例嗜铬细胞瘤患者发生难以控制的肾上腺出血；经腹膜后入路者中1例发生肾损伤。结论 腹腔镜下肾上腺手术应根据病变性质、肿瘤大小、位置及患者的具体情况选择手术入路，对体积较大、位于肾蒂前内方的肿瘤或血运丰富的嗜铬细胞瘤应采用经腹腔入路。

Comparison of transperitoneal versus retroperitoneal laparoscopic adrenalectomy

Objective To compare the surgical methods, advantages and disadvantages of transperitoneal with retroperitoneal 1 aparoscopic adrenalectomy, and to summarize the indications and contraindications of 1 aparoscopic adrenalectomy, and the choice between the 2 approaches. Methods Retrospective analysis of 105 cases who underwent laparoscopic adrenalectomy from July 1996 to December 2005 was conducted. Of these cases, 50 underwent transperitoneal 1 aparoscopic adrenalectomy and 55, retroperitoneal 1 aparoscopic adrenalectomy. The operative time, advantages and disadvantages, rate of conversion to open surgery and complications of the 2 modalities were compared. Results Of the 105 cases, 98 achieved successful operations and 7 had conversion to open surgery, including 5 (10% ) with transperitoneal access ( 3 due to complications and 2 due to adhesion) , and 2 with retroperitoneal access (1 due to renal injury and the other due to difficulty of exposure). In the cases undergoing transperitoneal access, the operative time was 50-180 min (mean, 82 min) ; the blood loss was 15 - 180 ml (mean, 65 ml) ; the time to out-of-bed activity was 36 h; and hospital stay was 5 - 14 d. In the cases undergoing retroperitoneal access, the operative time was 45 - 130 min (mean, 60 min) ; the time to out-of-bed activity was 24 h; and hospital stay was 3 -7 d. In transperitoneal access patients, 1 had hepatic injury, 2 with chromaffin tumor had uncontrollable hemorrhage. In retroperitoneal access patients, only 1 had kidney injury. Conclusions In laparoscopic adrenalectomy, the operative approach should be chosen based on the pathological changes, tumor size and position as well as the individual conditions of the patients. For patients with relatively larger tumors located anterior and medial to the kidney pedicle, or with chromaffin in abundant blood supply, transperitoneal approach should be performed.