腹腔镜肾上腺解剖学与手术入路研究

目的:借助腹腔镜进行肾上腺解剖学研究并建立合理的手术入路。方法:1999年10月至2009年3月我院共行腹膜后腹腔镜肾上腺手术45例;左侧27例,右侧18例。术前拍摄CT和/或MRI,术中摄取录相,术中、术后反复观察肾上腺的解剖部位、层面、周围筋膜、与肾筋膜腔关系等,并设计合理的手术入路。结果:肾前融合筋膜、腰肌筋膜、侧锥筋膜围成肾周间隙。肾周间隙又可再分为肾上腺间隙和肾筋膜间隙两部分。肾筋膜间隙由肾筋膜前后叶环形包绕而成,容纳肾脏、肾周脂肪和肾盂输尿管鞘。肾上腺间隙的前侧边是肾前融合筋膜,外侧边是肾筋膜,内侧边是膈肌脚。肾上腺间隙内包含肾上腺和肾上腺周围脂肪。结论:肾上腺位于肾筋膜腔外,术中沿肾脂肪囊外平面可迅速到达肾上腺。     

Expanding the indications for laparoscopic retroperitoneal adrenalectomy: experience with 81 resections

Background

Laparoscopic retroperitoneal (RP) adrenalectomy has gained popularity as the preferred approach over transabdominal (TA) method; however, surgeons have been reluctant to offer this operation to obese patients because of the concerns over inadequate working space and overall perceived higher rate of complications. The aim of the present study was to evaluate the feasibility and safety of RP adrenalectomy compared with TA adrenalectomy, specifically in morbidly obese patients.

Methods

All laparoscopic adrenalectomies performed at our institution between 2004 and 2012 were reviewed retrospectively. Presenting features, operative characteristics, and postoperative outcomes were evaluated. Complications were graded using Clavien system. Continuous variables were compared using Student t-test. Categorical variables were compared using χ²-test. Prediction models were constructed using linear or logistic regression as appropriate.

Results

Eighty-one RP and 130 TA procedures were performed, 26 (12.3%) and 60 (28.4%), respectively in obese patients (BMI > 30). Among the obese patients, operative time and estimated blood loss were less for RP (90 versus 130 min; P < 0.001 and 0 versus 50 mL; P < 0.001). Differences in the length of stay, overall mortality, incidence and severity of postoperative complications, and rates of readmission were not statistically significant between RP and TA procedures for all comers and in the obese patients. Controlling the operative characteristics and patient-specific factors, neither operative approach nor obesity was found to independently predict the postoperative complications.

Conclusions

Laparoscopic RP adrenalectomy is a safe and feasible technique for obese patients. In the obese patients and for all comers, it offers shorter operative time, decreased estimated blood loss, with comparable length of stay and morbidity and mortality rates. We therefore recommend that this technique should be considered for patients undergoing adrenal resection.     

Retroperitoneal hand-assisted laparoscopic surgery for endoscopic adrenalectomy

Although hand-assisted laparoscopic surgery (HALS) is very common in various laparoscopic procedures, it is rarely used for retroperitoneal endoscopic adrenalectomy because of the small working area. The authors evaluate HALS in endoscopic adrenalectomy with respect to its use as a rescue procedure in complicated cases. In their department, 47 patients underwent endoscopic adrenalectomies between 1998 and 2004. Mainly because of complicated anatomy, three primary aldosteronism cases were converted to retroperitoneal HALS. This involved making an additional 6 cm skin incision, into which the surgeon’s left hand was inserted, with the palm used to create a sufficient visual field and working area. The fingers were used for tactile sensation and blunt resection. For these three cases, successful retroperitoneal HALS in endoscopic adrenalectomy resulted in no mortality or morbidity. These findings indicate that this procedure is a feasible technique for complicated benign adrenal tumor cases.     

后腹腔镜单侧肾上腺全切除术和部分切除术对患者反应速度影响的研究

目的 探讨经后腹腔腹腔镜单侧肾上腺全切除及部分切除术后对机体反应速度的影响.方法 收集2015年8月至2017年5月我院收治的醛固酮瘤患者56例,其中女34例,男22例,年龄21~60岁;34例行单侧肾上腺全切术,22例行单侧肾上腺部分切除术.采取直尺垂直下降法测量并比较患者术前与术后3 d、术后1个月、术后3个月的反应速度.结果 56例患者术后随访均无肿瘤复发,56例患者术后3个月内反应速度均较术前慢(P<0.05),但术后3个月开始单侧肾上腺部分切除组反应速度较单侧肾上腺全切组快,两组差异有统计学意义(P<0.05).结论 单侧肾上腺切除术后对患者反应速度有影响,且单侧肾上腺全切较肾上腺部分切除影响大.但由于本研究病例数较少、随访时间较短,具体影响程度及机制有待进一步随访研究.     

后腹腔镜解剖学肾上腺肿瘤切除术的体会

【摘要】〓目的〓探讨经后腹腔镜解剖性肾上腺肿瘤切除术的手术方法和临床疗效。方法〓回顾性分析2010~2013年住院手术治疗的38例肾上腺肿瘤患者的临床资料,按既定的手术步骤施行后腹腔镜解剖性肾上腺肿瘤切除术,对临床资料、影像资料和手术录像等进行分析。结果〓38例手术均获成功,手术时间42~110 min(66±20.1),术中出血少,术后住院3~10 d,平均6.6 d。术后无严重并发症发生。术后随访6个月~2年未发现复发病例。结论〓后腹腔镜解剖性肾上腺瘤切除术,解剖层次清晰,手术操作较易掌握,疗效确切。     

腹膜后腹腔镜肾上腺部分切除术与全切除术的对比研究

目的：比较两种腹膜后腹腔镜肾上腺肿瘤切除术的不同,探讨肾上腺肿瘤选择不同术式的标准。方法：回顾分析2008年至2009年为76例患者施行腹膜后腹腔镜肾上腺肿瘤部分切除术（n=25）与肾上腺全切除术（n=51）的临床资料,对比分析两组的手术时间、术中出血量、术中并发症、术后止痛剂用量、术后住院时间及术后1个月激素水平、6个月血压。结果：74例顺利完成腹腔镜手术,2例中转开放,行肾上腺全切除术,两种术式肿瘤大小及位置、术中出血量、手术时间、住院时间、术中并发症发生率、术后镇痛剂使用量等差异无统计学意义（P〉0.05）,嗜铬细胞瘤患者不同术式并发症相比差异有统计学意义（P〈0.05）,全部病例术后3d至1个月激素替代率差异无统计学意义（P〉0.05）,皮质醇瘤患者术后3d激素替代率两组差异有统计学意义（P〈0.05）,随访6个月血压差异无统计学意义（P〉0.05）。结论：肾上腺部分切除术与全切除术均能有效切除肿瘤,肾上腺部分切除术能减少皮质醇症的术后激素替代率,嗜铬细胞瘤患者适宜行肾上腺全切除术。     

Synchronous bilateral endoscopic adrenalectomy: experiences after 18 operations

Background: Patients who undergo unilateral adrenalectomy are known to benefit from the endoscopic procedure. Only a few reports on bilateral endoscopic adrenalectomy exist. The optimal approach and the value of this operation were assessed in this study. Methods: For 18 patients, synchronous bilateral lateral adrenalectomy with intraoperative repositioning was performed for different indications. The transperitoneal and retroperitoneal approaches were varied on both sides. Results: With the reported procedure, the operative time diminished considerably. Blood loss was low, and no blood transfusions were required. No conversion to an open procedure was necessary. There were no intraoperative or postoperative complications, except for one death from pulmonary embolism. The mean postoperative hospital stay was 7 days, and the follow-up evaluation showed overall improvement. Conclusion: The risk associated with endoscopic bilateral adrenalectomy is low. Transperitoneal and retroperitoneal lateral adrenalectomy are recommended as approaches of choice. The authors advocate early bilateral adrenalectomy for Cushings disease after unsuccessful transsphenoidal operation and ectopic adrenocorticotropic hormone production from an inaccessible tumour.     

后腹膜返折韧带在后腹腔镜肾上腺切除术中的定位价值

目的探讨以后腹膜返折韧带为解剖标志在后腹腔镜肾上腺切除术中准确定位肾上腺的临床可行性及意义。方法回顾性分析我院2016年3月至2019年11月期间40例行后腹腔镜肾上腺切除术患者的临床资料,男22例,女18例,平均年龄54岁,肿瘤最大径1.2~5.6 cm,平均3.4 cm。以后腹膜返折韧带为解剖标志,设计手术第一步制作肾周筋膜切口的顶端标记点,沿此垂直身体纵轴向深面分离直达肾上腺完成准确定位。结果本组40例均准确定位肾上腺后完成手术。平均手术时间45 min,平均术中出血量20 ml,平均下床活动时间12 h,平均术后住院天数4 d。结论在后腹腔镜肾上腺切除术中,以后腹膜返折韧带为解剖标志,制作肾周筋膜切口的顶端标记点,可准确定位肾上腺,值得在临床推广使用。     

腹腔镜经腹膜后解剖性肾上腺(腺瘤)切除术的体会

目的:探讨腹腔镜经腹膜后解剖性肾上腺(腺瘤)切除术的手术方法及临床效果。方法:为48例患者按既定手术步骤施行解剖性肾上腺(腺瘤)切除术。制备腹膜后腔操作空间后,先将肾上极腹膜外脂肪向下推至髂窝,然后避开腹膜返折纵行切开肾后筋膜外层,进入肾周筋膜固有间隙,扩大腹膜后腔,并在此间隙快速找到肾上腺,根据术前诊断及术中情况选择行肾上腺或腺瘤切除术。结果:48例手术均获成功,术中出血少,均未输血,无严重并发症发生。术后住院4～8 d,平均5.2 d。结论:腹腔镜经腹膜后解剖性肾上腺(腺瘤)切除术步骤明确,解剖层次清晰,疗效确切,为肾上腺疾病的微创外科治疗提供了更安全的选择。     

基于肾上腺血管解剖的后腹腔镜肾上腺切除技术的改进及临床应用

目的:基于对肾上腺血管解剖的理解,探讨后腹腔镜肾上腺切除术的新技术。方法:2013年12月至2015年5月共收治179例肾上腺肿瘤患者,其中男92例,女87例;肿瘤位于右侧88例,左侧91例;患者12~79岁,平均(47.8±9.8)岁;肿瘤直径0.8~11.5 cm,平均(2.8±1.3)cm。根据患者病情完善术前准备后均由同一术者根据以下策略行后腹腔镜肾上腺切除术:(1)腹膜后空间建立后沿腰大肌表面游离并纵行打开肾筋膜直至膈肌脚,寻及膈下动脉并结扎切断肾上腺上动脉;(2)寻及肾动脉,紧贴肾动脉及肾上极内侧缘夹角向深面游离,结扎肾上腺中、下动脉;(3)通过肾动脉及肾脏内侧缘所形成的"中央静脉三角"寻找肾上腺中央静脉并离断;(4)在肾脏、肾上腺之间游离,到达肾前融合筋膜层面,将肾上腺与肾脏重叠部分分离;(5)离断肾上腺周围相连的结缔组织,完整切除肾上腺。结果:178例手术获得成功,1例中转开放手术;手术时间12~68 min,平均(30.2±10.3)min;出血量10~110 ml,平均(20.6±12.7)ml;术后住院1.5~3.9 d,平均(2.3±0.8)d;2例术中出现腹膜损伤,术后随访期间未见肿瘤复发及转移。结论:此操作方法更加直接的处理肾上腺血供,减少了出血的几率,游离面较少,根据肾上腺解剖关系不用刻意寻找肾上腺肿瘤,操作更加省时、简单。     

后腹腔镜肾上腺切除术36例报告

目的探讨后腹腔镜肾上腺切除术的临床应用价值。方法经后腹腔行腹腔镜。肾上腺切除术36例，其中肾上腺皮质腺瘤15例，肾上腺皮质结节状增生3例，嗜铬细胞瘤6例，原发性醛固酮增多症6例，肾上腺囊肿3例，肾上腺节细胞神经瘤2例，髓脂肪瘤1例。对其临床资料进行分析总结。结果30例获成功，6例术中转开放性手术。后腹腔镜肾上腺切除手术时间为35～200min，平均120min。术中出血量为10～500ml，平均85ml。术后平均住院天数10天。29例获得3～9个月随访，无严重并发症和肿瘤复发。结论后腹腔镜肾上腺手术具有创伤小、疗效确切、并发症少和病人恢复快等优点，是治疗肾上腺占位性疾病的首选方法，但存在学习曲线。     

两种手术方式对后腹腔镜下肾上腺嗜铬细胞瘤切除术血液动力学影响的对比研究

目的探讨不同手术方式对后腹腔镜下肾上腺嗜铬细胞瘤切除术血液动力学变化的影响。方法回顾性分析我院自2002年3月至2010年12月完成的58例后腹腔镜下。肾上腺嗜铬细胞瘤切除术,比较术中不同的后腹腔建立方法、CO2气腹压力、肾上腺中央静脉处理策略对血液动力学变化的影响。结果在后腹腔建立期,与术前相比,A组的MAP（平均动脉压）和HR（心率）明显增高、增快（P〈0．05）,B组无明显改变;在肿瘤游离期,两组的MAP和HR都明显增高、增快（P〈O．05）,B组变化程度低于A组（P〈O．05）;在肿瘤切除后期,两组都有MAP降低和HR增快（P〈0．05）,B组的变化程度比A组低（P〈0．05）。两组各期CVP（中心静脉压）无明显改变（D0．05）。结论后腹腔镜下嗜铬细胞瘤切除术中采用指扩法、低CO2气腹压力、优先处理肾上腺中央静脉在后腹腔建立期、肿瘤游离期、肿瘤切除后期对平均动脉压和心率的影响较小,血液动力学环境较稳定。     

肾上腺病变的后腹腔镜手术切除

目的：探讨后腹腔镜手术切除肾上腺病变的效果。方法：对65例肾上腺病变患者行后腹腔镜肾上腺病变切除术。结果：65例手术时间为45～219min，平均为74min。术中出血20～300ml，平均50ml。患者术后第2天下床活动并进流质饮食；引流管于术后2～3天拔除；穿刺孔周围皮下气肿2～3天后自动吸收；平均住院时间6d。问卷调查，患者均于术后7～20天(平均12天)恢复正常生活。结论：后腹腔镜下手术切除肾上腺病变是一种微创、安全、有效、患者住院时间短、术后恢复快的术式。     

Endoscopic adrenalectomy: an analysis of the transperitoneal and retroperitoneal approaches and results of a prospective follow-up study

Background Endoscopic adrenalectomy is currently performed using either a retroperitoneal or transperitoneal approach. The aim of this study was to determine which of these is the optimal surgical technique in a prospectively designed analysis of a large series of patients operated on by a single team over a 10-year period.Methods From February 1994 to March 2004, 267 endoscopic adrenalectomies (retroperitoneal in 132 patients and transperitoneal in 135 patients) were performed in 245 consecutive patients. There were 102 right lateral and 121 left lateral procedures (22 patients had a bilateral procedure). The most prevalent indication was incidentaloma (35.9%), followed by pheochromocytoma and Conn’s adenoma.Results The endoscopic procedure was performed in 238 of 245 patients (97.1%). The conversion rate was 1.5% for the transperitoneal approach and 3.8% for the retroperitoneal approach. No statistically significant influence was noted for the parameters of intraoperative blood loss, rate of postoperative complications, and duration of hospital stay with regard to the surgical technique. The operative time and the learning curve proved to be significantly longer for the retroperitoneal adrenalectomy. In addition, a variance analysis identified tumor size (>5 cm) as a significant factor influencing the operative time, whereas body mass index and localization (right/left lateral) did not prove significant.Conclusion Independent of the underlying pathology, endoscopic adrenalectomy using either the trans- or retroperitoneal approach can be performed in 96-98% of all patients. Differences between the two techniques in operative time and learning curves clearly favor the transperitoneal adrenalectomy.     

后腹腔镜解剖性肾上腺切除术

目的介绍后腹腔镜解剖性肾上腺切除术的手术方法及临床效果。方法2000年2月至2005年10月,对800例患者采取后腹腔镜解剖性肾上腺切除术。常规制备后腹腔操作空间。切开Gerota筋膜后,按顺序分别进入3个相对无血管解剖层面进行分离。第一分离层面位于肾脏内上方脂肪囊与前层Ger0ta筋膜之间,此层面可以在手术初期快速找到肾上腺;第二分离层面位于肾外上方脂肪囊与后层Gerota筋膜之间;第三分离层面位于肾上腺下方与肾上极之间。最后处理肾上腺中央静脉。依术前诊断和术中情况选择行肾上腺全切或次全切术。结果除1例嗜铬细胞瘤(肿瘤直径7.8 cm)患者因肾上腺肿瘤与肝脏及下腔静脉粘连紧密行中转开放手术外,全部手术均成功完成。平均手术时间(45±19)min,平均术中出血量(25±11)ml。恢复饮食和下床活动时间分别为1.2 d和1.0 d。12例(1.5%)出现术后皮下气肿、皮下血肿或切口感染。除6例特发性肾上腺增生患者术后1年高血压复发外,其余患者临床症状均消失或明显好转。结论后腹腔镜解剖性肾上腺切除术解剖层次清楚,术野清晰.疗效确切,为肾上腺外科疾病的治疗提供了更加安全的选择。     

后腹腔镜下肾上腺肿物切除术的临床价值

目的：评价后腹腔镜下肾上腺肿物切除术的临床应用价值。方法：经后腹腔镜行肾上腺肿物切除术33例,其中肾上腺皮质腺瘤15例,肾上腺皮质结节状增生3例,嗜铬细胞瘤3例,醛固酮增多症6例（腺瘤型5例,结节状增生型1例）,肾上腺囊肿3例,肾上腺节细胞神经瘤2例,髓脂肪瘤1例。结果：32例获得成功,1例中转开放手术,无严重并发症,疗效满意。结论：后腹腔镜下肾上腺手术具有创伤小、出血少、并发症少等优点,实用性强,临床疗效可靠。     

后腹腔镜解剖性肾上腺肿瘤切除术的治疗体会:附46例报告

目的 探讨后腹腔镜下肾上腺手术解剖定位的方法及临床应用价值.方法 对2009年9月至2011年11月本院所收46例肾上腺肿瘤患者施行后腹腔镜下切除术,其中无功能腺瘤17例,原发性醛固酮增多症13例,皮质醇增多症12例,嗜铬细胞瘤4例.常规制备后腹腔操作空间,打开Gerota筋膜,转向后壁沿腰大肌向上分离至项壁膈肌,分离前壁腹膜肾筋膜与脂肪囊间隙,沿肾上极平面横断分离寻找肾上腺,根据术中情况行肾上腺肿瘤切除或全切除术.结果 46例均成功施行腹腔镜下切除,其中1例因与下腔静脉粘连严重而部分旷置,平均手术时间83±21 min,平均出血量42±15 ml.1例(2.1％)术中胸膜穿孔,1例(2.1％)损伤下腔静脉,均在腹腔镜下完成修补.平均术后住院时间5.2 d,随访3 ～27个月,无远期并发症,46例良性肿瘤未见复发.结论 沿着正确的解剖平面寻找分离肾上腺具有快速、出血少、定位准确的优点,后腹腔镜下肾上腺手术安全、创伤小、恢复快,应为肾上腺手术的首选方法.     

后腹腔镜下肾上腺嗜铬细胞瘤切除术37例疗效观察

目的探讨后腹腔镜下肾上腺嗜铬细胞瘤切除术的安全性及治疗效果。方法行后腹腔镜肾上腺嗜铬细胞瘤切除术37例病例资料。肿瘤位于左侧14例,右侧22例,双侧1例。肿瘤直径0.8-8.9cm,平均4.1±2.2cm。4例（13.2％）血压正常,33例（86.8％）血压升高,以头晕、头痛、心悸、恶心、呕吐、腹痛等为主要临床表现,典型三征症患者5例。术前将红细胞比容控制在45％以下,心率90次/min,血压在正常范围后,连续监测3d血压无明显波动后在全身麻醉下行后腹腔镜下肾上腺嗜铬细胞瘤切除术。结果36例手术成功,1例中转开放手术。手术时间143±16min,术中估计出血量96±34ml。术后住院时间5±2d。术中术后未发生重大并发症,肿瘤局部无复发。结论后腹腔镜下肾上腺嗜铬细胞瘤手术具有微创、出血少、恢复快等优点,充分的术前准备、正确的术中操作是取得手术成功、减少术后并发症的关键。     

达芬奇机器人辅助腹膜后腹腔镜肾上腺切除术

目的探讨达芬奇机器人辅助腹膜后腹腔镜肾上腺切除术（RARA）的安全性与可行性。 方法2016年3月至2017年3月,我科以腹膜后途径行RARA患者26例,并与同时期内的经腹腔途径达芬奇机器人辅助肾上腺切除术（RATA）46例,以及常规腹膜后腹腔镜肾上腺切除术（RLA）122例的手术时间（OT）、失血量（EBL）、住院天数（HS）、恢复进食时间（TRFI）进行比较。 结果三组患者术前一般资料差异无统计学意义。RARA的手术时间（45±6）min,失血量（26±5）ml,住院天数（3.6±0.8）d与RATA[（53±4）min、（22±3）ml、（3.5±1.3）d]及RLA[（43±3）min、（26±3）ml、（2.9±0.5）d]间差异均无统计学意义（P>0.05）,但在术后早期进食方面表现优于RATA[（18.8±2.2）h vs （24.8±4.7）h,P=0.036]。 结论RARA是一种安全可行的手术方式,有利于患者术后早期肠道功能恢复。     

后腹腔镜下肾上腺嗜铬细胞瘤切除术56例体会

目的探讨后腹腔镜下手术治疗肾上腺嗜铬细胞瘤的有效性和安全性。方法行后腹腔镜肾上腺嗜铬细胞瘤切除术56例。肿瘤位于左侧24例、右侧30例、双侧2例。肿瘤直径1．5～10．0cm，平均（4．5±2.0）cm。主要临床表现为高血压者45例；无高血压者5例，主诉心悸、恶心、呕吐、腹痛、消瘦等；无症状经体检发现者6例。56例均行内分泌常规检查和影像学检查。术前常规行扩容、降压及对症处理，术中术后严密监测血压变化并给予相应处理。结果55例手术成功，1例中转开放手术。手术时间（52±22）min，术中估计出血量（74±34）ml．术后住院时间（5±1）d。术中术后未发生重大并发症。术中血压波动≥20rnmHg（1mmHg=0．133kPa）21例。病理报告均为嗜铬细胞瘤。随访5～36个月，36例患者术后2个月内血压恢复正常，9例仍需口服降压药物。肿瘤局部无复发。结论后腹腔镜下肾上腺嗜铬细胞瘤手术具有微创、出血少、恢复快等优点，充分的术前准备、正确的术中操作是手术安全的保证。