泌尿外科单孔多通道腹腔镜技术在中国的应用与创新

目的 系统回顾并总结评价单孔腹腔镜技术在中国泌尿外科领域的发展现状. 方法 通过检索2009年1月至2012年7月万方数据资源系统、中国知网CNKI、维普期刊、中国生物医学文献数据库、GoogleScholar搜索引擎、MEDLINE等数据库中我国学者公开发表的有关泌尿外科单孔腹腔镜手术文献,分析泌尿外科单孔腹腔镜技术在国内的临床应用特点和变化趋势. 结果 共纳入全国 66家单位205篇相关文献,其中科学引文索引(science citation index,SCI)期刊收录文献26篇,中文期刊文献179篇.文献类型构成为:病例报告或经验介绍133篇(64.9％),对比研究13篇(6.3％),综述、述评20篇(9.8％),护理相关28篇(13.7％),动物实验6篇(2.9％),培训相关5篇(2.4％).共报道临床病例1790例,其中上尿路手术1018例(56.9％),下尿路手术104例(5.8％),男科及其他手术668例(37.3％).肿瘤相关手术336例(18.8％),需重建的手术334例(18.7％).按手术通道分为单孔多通道手术1043例(58.3％),单切口多套管手术747例(41.7％).单孔多通道手术中选择商业化专用装置者476例(45.6％),选择自制装置者567例(54.4％).按入路途径分为经腹腔途径1065例(59.5％),经腹膜外(腹膜后和腹膜前)途径725例(40.5％);按切口部位分为经脐单一切口1047例(58.5％),经脐外单一切口743例(41.5％).共涉及25种手术方式:①上尿路手术,包括肾上腺切除、肾囊肿去顶减压、单纯性肾切除(无功能肾、重复肾等)、肾癌根治性切除、肾脏部分切除、肾肿瘤冷冻消融、活体供肾切取、肾蒂周围淋巴管结扎、肾盂或输尿管癌根治、肾盂或输尿管上段结石切开取石、肾盂输尿管狭窄成型、输尿管松解等手术;②下尿路手术,包括膀胱癌根治性切除+尿流改道、膀胱癌膀胱部分切除、经膀胱膀胱肿瘤剜除、输尿管膀胱再植、前列腺癌根治(经腹腔、经腹膜外、经膀胱)、经膀胱前列腺剜除、盆腔淋巴结清扫等手术;③男科手术,包括精索静脉曲张结扎、隐睾下降固定、男性假两性畸形整形、小儿鞘状突未闭修复等手术;④其他手术,包括腹膜透析管放置、腹膜后淋巴结清扫术.单一术式病例数前三位的依次为:精索静脉曲张结扎术601例(33.6％)、肾囊肿去顶减压术408例(22.8％)、肾上腺切除术179例(10.0％).总体手术中转率为5.5％,总体手术并发症发生率为3.4％. 结论 泌尿外科单孔多通道腹腔镜技术在国内已广泛普及,开展术式几乎涵盖了所有传统腹腔镜手术类型,但目前仍以非重建手术治疗泌尿系良性病变为主要适应证.总体上说,单孔腹腔镜技术在国内泌尿外科领域的应用仍处于初级探索阶段,需要更多的自主创新和规范科研工作,以更好地评价单孔腹腔镜技术在泌尿外科手术中的应用价值.     

单孔腹腔镜下根治性膀胱切除术10例报告

目的 探讨单孔腹腔镜根治性膀胱切除术的可行性及初步经验.方法 采用单孔腹腔镜技术完成根治性膀胱切除术10例.男9例,女1例.取下腹正中3～4 cm切口,置入QuadPort(2例)或自制开口器(2环1套法,8例)建立单孔腹腔镜手术通道,术中采用常规和预弯腹腔镜器械.手术步骤包括双侧标准盆腔淋巴结清扫、根治性膀胱切除及开放构建全去带乙状结肠原位新膀胱.结果 10例手术顺利.无中转开放手术或传统腹腔镜手术,未增加其他通道.单孔部分手术时间130～330 min,平均243 min.术中失血50～600 ml,平均270 ml,5例需输浓缩红细胞2～4 U.盆腔淋巴结、尿道及输尿管切缘均阴性.病理报告均为尿路上皮癌T1N0M0 2例,T2aN0M0 6例,T3aN0M0 2例.无围手术期死亡及严重并发症的发生.8例完成6个月以上的随访,白天排尿均完全可控,4例有夜间遗尿,未见肿瘤复发和远处转移.结论 单孔腹腔镜膀胱癌根治性切除术安全可行,美容效果较好,短期随访肿瘤控制效果好.自制开口器制作简单,操作方便,气密性好,成本低,能够完成单孔腹腔镜手术.

Abstract：

Objective To present our initial experience of pure laparoendoscopic single-site surgery (LESS) for radical cystectomy and bilateral pelvic lymph node dissections. Methods 10 patients with pathology confined bladder urothelial carcinoma underwent laparoendoscopic single-site radical cystectomy, including 9 males and 1 female. After a 3-4 cm lower median abdominal incision was made, quadport or homemade single multichannel port was inserted, and conventional and prebent laparoscopic instruments were utilized. The surgical procedure included bilateral pelvic lymphadenectomies, radical cystectomy and building with a sigmoid orthotopic neobladder by open surgery.Results No extra port needed, neither conversion to open or conventional laparoscopic surgery. The time of LESS procedure ranged from 130 to 330 min (mean 243 nin). Estimated blood loss ranged from 50 to 600 ml (mean 270 ml). 5 patients needed blood transfusion of 2 to 4 units. The pathologic evaluation revealed bladder urothelial carcinoma, negative margins and negative pelvic lymph node involvement. No mortality or severe complications were observed perioperatively. After followup of more than 6 months, all revealed controllable urination at daytime, while 4 revealed nocturnal incontinence and needed one or two pads during nighttime. No evidence of recurrent or metastatic disease was detected. Conclusions LESS radical cystectomy and bilateral lymphadenectomies was safe and feasible, and short-term follow-up showed good tumor control outcomes. Homemade single multichannel port made of two elastic ring and glove was simple and effective.     

Laparo-Endoscopic Single Site (LESS) cosmesis: Patients perception of body image distortion after LESS surgery

BackgroundRelative to conventional laparoscopy, Laparo-Endoscopic Single Site (LESS) surgery has been associated with improved cosmesis. This study investigated preoperative and postoperative patient perceptions of LESS surgery and what factors may affect those perceptions.MethodsPatients undergoing LESS Surgery were queried before and after their operations. Body image and other factors were assessed preoperatively and postoperatively in 881unselected patients undergoing LESS surgery utilizing Likert scale questionnaires. Responses were collated and analyzed. Data are reported as median (mean ± SD), where appropriate.Results881 patients studied had a median age of 59 (57 ± 15.3) years and had a median Body Mass Index of 27 (28 ± 6.2) kg/m². 65% were women. 343 (39%) had undergone a previous abdominal operation(s). Prior to LESS surgery, patients reported neutral body image scores and rated their overall appearance satisfaction as 40% (37% ± 30.7) on a Visual Analog Scale (VAS). 68% were unwilling to undergo LESS surgery if it involved more risk relative to traditional laparoscopy as safety was their number one concern. Postoperatively, patients reported a significant improvement in body image perception and safety was no longer their foremost concern.ConclusionPreoperatively, patients are most concerned with safety (e.g. risk) with secondary concerns of cost and pain but they were less concerned with their appearance. Postoperatively, safety is much, much less of an issue (because it has been achieved) and appearance is more paramount with significant improvements in their self-assessed appearance. With LESS surgery patients indicate a high level of satisfaction with cosmesis.     

单孔腹腔镜下输卵管异位妊娠手术与传统腹腔镜手术的对比

目的探讨单孔腹腔镜技术用于输卵管异位妊娠手术的益处和可行性。方法总结11例单孔腹腔镜下输卵管异位妊娠手术的操作经验,并与20例传统腹腔镜下异位妊娠手术作比较,观察二者适应证、手术时间、出血、术后疼痛、并发症等方面是否有显著差异。结果 11例患者大多应用以软性入路平台为主的入路方式,部分配合使用特殊的腹腔镜器械进行操作。其术前β血人绒毛膜促性腺激素水平、内出血量、术中出血、术后恢复等指标与传统腹腔镜技术比较无显著差异,但手术时间较后者延长且有显著性差异。结论单孔腹腔镜技术用于输卵管异位妊娠手术是一种简单可行的、适于单孔腹腔镜操作技术入门学习的手术方式,且手术切口美观,手术效果确切。     

单孔腹腔镜输尿管切开取石术的初步应用体会

目的 探讨经腹膜后途径,行单孔腹腔镜输尿管切开取石术的可行性及疗效.方法 2010年6月至2011年2月,收治8例单侧输尿管上段结石患者,采用自制多通道套管,经腹膜后途经,行单孔腹腔镜输尿管切开取石术.以同一术者完成的15例传统腹腔镜经腹膜后输尿管切开取石术作为对照组.对比两组的手术时间、出血量、手术并发症、平均住院时间、术后镇痛药应用时间及腹膜后引流管停留时间等指标.结果 所有单孔腹腔镜手术均获成功、无1例转为传统腹腔镜或开放术式.结石平均长径18 mm,平均手术时间131±16min,失血量30±5 ml,1例术后出现尿漏、于术后第3天停止;无其他手术并发症.两组手术时间、出血量、腹膜后引流管停留时间等无明显差异.单孔腹腔镜组在平均住院时间、术后镇痛药应用天数及美容效果等方面优于传统腹腔镜组.两组患者均获得治愈.结论 单孔腹腔镜输尿管切开取石术是可行、有效的,适用于治疗部份体积较大的输尿管结石病例,其远期效果有待增加病例数进一步评估.     

泌尿外科单孔腹腔镜手术 209 例临床应用分析

目的 报道单中心209例泌尿外科单孔多通道腹腔镜手术,并评价其临床应用特点和价值. 方法 前瞻性收集2008年12月至2012年7月209例泌尿外科单孔多通道腹腔镜手术患者的临床资料和围手术期数据.男121例,女88例.年龄(52.8 ±14.5)岁.体质指数(body mass index,BMI) (23.5 ±3.1 )kg/m2.既往腹盆腔手术史42例(20.1％).麻醉评分( american society of anesthesiologists score,ASA)(2.0±0.3)分.合并高血压61例(29.2％),糖尿病27例(12.9％).术前诊断为肾肿瘤70例(33.5％),肾上腺占位42例(20.1％),肾囊肿22例(10.5％),输尿管上段结石22例(10.5％),无功能肾脏19例(9.1％),BPH 10例(4.8％),其他24例(11.5％).探讨总体手术适应证、手术并发症和手术中转情况等临床特点,并将所有手术按完成时间先后分为两个阶段,每个阶段各22个月,进行相关参数的比较分析. 结果 本组共完成手术209例,其中上尿路手术193例(92.3％),肿瘤相关手术1 16例(55.5％),术中需重建的手术34例(16.3％),经腹腔途径手术169例(80.9％),经膀胱途径手术11例(5.3％),经脐切口手术98例(46.9％).总体手术中转率8.1％(17/209),其中增加一个5或10 mm辅助孔9例(4.3％),中转普通腹腔镜手术4例(1.9％),中转开放手术4例(1.9％).总手术并发症发生率16.3％(34/209),术中并发症发生率4.8％( 10/209),术后并发症发生率11.5％(24/209).两个阶段比较分析显示,手术总量从第一阶段的77例上升到第二阶段的132例,平均每月完成手术量分别为(3.5±3.0)和(6.0±3.5)例,两组比较差异有统计学意义(P＜0 05).第二阶段中肿瘤相关手术、根治性肾切除术和肾上腺切除术比例增高,经脐切口手术、肾囊肿去顶减压术和经膀胱前列腺剜除术比例减少,与第一阶段比较差异均有统计学意义(P＜0.05). 结论 对于具备丰富腹腔镜操作经验的术者,可用单孔腹腔镜技术成功完成各类泌尿外科手术,但仍有一定的手术并发症和手术中转风险,应严格把握手术适应证,尤其是初学者不宜开展需复杂重建或恶性肿瘤相关的单孔腹腔镜手术,应始终把手术安全和疗效放在首位.     

SPIDER surgical system for urologic procedures with laparoendoscopic single-site surgery: from initial laboratory experience to first clinical application

This case study describes our initial laboratory experience using the SPIDER surgical system (TransEnterix, Morrisville, NC, USA) for laparoendoscopic single-site surgery (LESS) urologic procedures and reports its first clinical application. The SPIDER system was tested in a laboratory setting and used for a clinical case of renal cyst decortication. Three tasks were performed during the dry lab session, and different urologic procedures were conducted in a porcine model. The time to complete the tasks and penalties were registered during the dry lab session. Perioperative outcomes and subjective assessment by the surgeons were registered.The surgeons had a positive experience with the SPIDER system, with a mean overall score of 3.6 (on a scale of 1-5). The surgeons were able to gain proficiency in performing tasks regardless of their level of expertise. The highest scores recorded were for ease of device insertion, instrument insertion and exchange, and triangulation. The lowest scores were for retraction. During the clinical case, the platform provided good triangulation without instrument clashing. However, retraction was challenging because of the lack of strength and precise maneuverability with the tip of the instruments fully deployed. The SPIDER system offers intuitive instrument maneuverability and restored triangulation without external instrument clashing. Further refinements are awaited to define its role in the urologic LESS armamentarium.     

单孔腹腔镜体外缝合训练模式的探索

目的探索适合体外缝合训练的模拟操作箱、入路平台(port)及缝合方式。 方法由1位有单孔腹腔镜操作经验的手术医师采用改良腹腔镜模拟训练箱进行缝合操作。缝合方式包括单手法和双手法,缝合目标包括固定目标和活动目标。以不使用port作为对照,比较2种缝合方式在4种不同的port中缝合30针所需的时间。另5位有多孔、无单孔腹腔镜操作经验的医师接受缝合训练,采用无port缝合活动目标,每次训练缝合30针,每周1次,记录分析缝合时间。 结果采用经改良的常规腹腔镜模拟箱可顺利完成缝合训练。缝合固定目标时,单手法耗时明显少于双手法(P<0.05)。缝合活动目标时,双手法耗时明显少于单手法(P<0.05)。较大port的缝合耗时较久。训练阶段缝合时间前3次逐步缩短[(16.5±0.2)s、(13.4±0.3)s、(12.0±0.1)s](P<0.05),第4、5次[(12.3±0.2)s、(12.3±0.2) s]与第3次比较,差异无统计学意义(P>0.05)。 结论采用改良的常规腹腔镜模拟操作箱、无需port可完成单孔腹腔镜缝合训练。训练过程需强调单手操作,较大port不适合单孔下的训练,平均3次训练可完成体外缝合的学习曲线。     

经脐单孔腹腔镜在晚期卵巢恶性肿瘤初始评估及活检中的应用

目的对于拟诊晚期卵巢恶性肿瘤的患者,探讨经脐单孔腹腔镜探查在初始评估及组织活检中的可行性及安全性。方法回顾性分析重庆医科大学附属第一医院妇科2016年5月至2020年5月对63例拟诊晚期卵巢恶性肿瘤患者实施腹腔镜探查及活检术,其中30例采用经脐单孔腹腔镜探查(单孔组)、33例采用多孔腹腔镜探查(多孔组)。单孔组采用经脐2~3 cm单切口操作,多孔组采用4孔操作。所有患者满足2个条件:缺乏细胞学证据、术前CT评分(Suidan评分)难以完成满意的初期肿瘤细胞减灭术(primary debulking surgery,PDS)。手术包括全面探查评估(Fagotti评分)和组织活检。比较两组的手术资料、围手术期并发症、术后切口愈合及切口转移发生率。结果63例患者均顺利完成手术探查及组织活检。单孔组Ⅲ期28例、Ⅳ期2例,无增加穿刺孔,2例中转行开腹PDS;多孔组Ⅲ期31例、Ⅳ期2例,无中转开腹手术。两组平均手术时间[(88.1±22.1)min比(81.4±20.0)min,P>0.05]、术中出血量[(39.7±33.8)ml比(40.6±62.1)ml,P>0.05]。两组的围手术期并发症差异无统计学意义。单孔组无脐疝、无切口转移;多孔组1例脐疝、2例发生切口转移。结论在晚期卵巢恶性肿瘤探查及活检中,单孔腹腔镜安全可行,取标本方便,可保护切口,可能优于多孔腹腔镜在此类患者中的应用。     

5 mm微切口单孔腹腔镜全子宫切除术初探

目的初步探讨5 mm微切口单孔腹腔镜全子宫切除术的安全性与可行性。 方法回顾性分析1例接受5 mm微切口单孔腹腔镜全子宫切除术患者的临床资料并进行总结分析。患者为52岁女性,因发现宫腔占位入院,诊刮术后病理提示为子宫内膜复杂性增生过长伴不典型增生,行5 mm微切口单孔腹腔镜全子宫切除术。 结果手术成功完成,手术总时间155 min,术中未增加其他通道,无中转开腹,术中出血量约50 ml。患者术后1 d即恢复肠蠕动,术后2 d拔除尿管后即恢复排尿功能。脐部切口为Ⅱ/甲愈合,无明显瘢痕。术后病理提示子宫内膜复杂性增生。患者恢复情况良好,对治疗效果十分满意。 结论在严格把握手术适应证的前提下,5 mm微切口单孔腹腔镜全子宫切除手术应用于部分条件适合的患者可能是安全可行的。     

"筷子技术"用于经脐单孔腹腔镜全子宫切除术的可行性和安全性研究

目的"筷子技术"用于经脐单孔腹腔镜(laparoendoscopic single-site surgery，LESS)全子宫切除术与传统多孔腹腔镜(traditional laparoscopic，TL)全子宫切除术，进行围手术期结局，验证其可行性和安全性。 方法采用回顾性队列研究，纳入2016年12月至2019年6月期间，于陆军军医大学附属第一医院妇产科，行LESS全子宫切除术与同期TL全子宫切除术的患者。比较两组的手术时间、术中出血量、术后排气时间、术后12 h和24 h疼痛视觉模拟评分(visual analogue scale, VAS)、术后住院时间、术中和术后并发症发生情况。 结果研究共纳入297例患者临床资料，其中LESS全子宫切除术107例(LESS组)、TL全子宫切除术190例(TL组)。两组均顺利完成手术，无中转开腹。两组患者基线均衡。LESS组和TL组的手术时间分别为131 min(102，155)min和125.5 min (92.8，155)min，差异无统计学意义(P>0.05)；术中出血量分别为100 ml(100，200)ml和100 ml(100，150)ml，差异无统计学意义(P >0.05)；术后排气时间、术后12 h和24 h VAS、围手术期并发症等，差异无统计学意义(P>0.05)；两组阴道残端均愈合良好。LESS组术后住院时间比TL组短，差异有统计学意义(P<0.05)。分别比较子宫≥12孕周、子宫<12孕周的患者，LESS组与TL组的手术时间、术中出血量、术后排气时间、术后12 h和24 h VAS、围手术期并发症，差异无统计学意义(P >0.05)。子宫<12孕周LESS组比TL组的术后住院时间缩短，差异有统计学意义(P<0.05)。 结论"筷子技术"用于LESS全子宫切除的围手术期结局与TL相似，初步证实了其在LESS术中的可行性和安全性。     

Mechanical evaluation of three access devices for laparoendoscopic single-site surgery

Background

Many access devices have been developed for laparoendoscopic single-site surgery (LESS) during recent years. However, investigations are needed to determine which port is most suitable for this relatively new technique. The aim of this study was to evaluate commonly used ports using mechanical approaches in a training simulator. Any port that required less force and shorter surgery times had superior maneuverability.

Methods

The following three commercially available access devices were evaluated: Multi-ports, TriPort, and single-incision laparoscopic surgery (SILS) Port. A LESS mechanical evaluation platform was developed to investigate the forces that acted on the instruments in the ports while moving along horizontal and vertical axes. In addition, a strain–force measurement system was used to compare the average load on the ports when performing standard maneuvers. Additionally, the task completion time was recorded when the maneuvers in these ports were completed.

Results

During the horizontal displacement of the instrument, the traction forces of the Multi-ports were lower than those of the SILS Port, which were lower than those of the TriPort. The average traction forces were significantly different in pairwise multiple comparisons (P < 0.05). When the instrument was inserted into the ports, the vertical friction forces of the Multi-ports were the lowest and those of the TriPort were the highest. On extraction of the instrument, the friction forces of the Multi-ports remained the lowest, followed by those of the TriPort and SILS Port. There were statistically significant results among all the devices (P < 0.05). The average load required to perform the task was less for the SILS Port than that for the TriPort (P < 0.05). Similarly, the average load for the Multi-ports was significantly less than that for the TriPort (P < 0.001). The participants who used the Multi-ports had significantly faster task times than those who used the SILS Port or TriPort (P < 0.005).

Conclusions

Compared with the TriPort and SILS Port, the Multi-ports was associated with the least average load and the shortest task performance times in a training simulator. This study demonstrates that the Multi-ports may offer superior maneuverability for LESS.     

经脐单孔腹腔镜下根治性肾切除术11例报告

目的 探讨采用自制单孔腹腔镜通道行经脐单孔腹腔镜下根治性肾切除术的安全性和初期疗效. 方法 2010年7月至2011年11月肾细胞癌患者11例,男5例,女6例.年龄37～68岁,平均49岁.体质指数(body mass index,BMI)18.4～ 30.4 kg/m2,平均24.2 kg/m2.腹部B超及肾脏CT检查提示11例均为肾细胞癌,肿瘤位于左肾7,右肾4例;位于肾上极3例、中部4例、下极4例;2例可疑淋巴结转移,1例患肾并存肾囊肿,未见其他腹部脏器转移征象.肿瘤临床分期:T1aN0M01例,T1bN0M05例,T2aN0M03例,T1bN1M02例.全麻下行经脐单孔腹腔镜下根治性肾切除术,采用自制单孔腹腔镜通道,手术步骤与传统腹腔镜下肾根治性切除术相似. 结果 本组11例手术中8例顺利完成,2例中转为传统腹腔镜手术,1例中转为手助腹腔镜手术,无中转开放手术.手术时间155～ 297 min,平均225 min.术中出血量50 ～900 ml,平均271 ml.术后病理诊断均为肾细胞癌,病理分期为T1a3例,T1b5例,T2a3例.术后视觉模拟疼痛评分3～6分,平均4分.住院时间5～15 d,平均10d.术后随访8～24个月,平均17个月,11例患者均存活,对切口外观满意,无肿瘤复发及转移. 结论 采用自制单孔通道行经脐单孔腹腔镜下根治性肾切除术刘部分肾细胞癌患者是一种安全的治疗方式,切口美观性好,初期肿瘤学效果满意.     

Laparoendoscopic single-site surgery in urology: worldwide multi-institutional analysis of 1076 cases

Background

Laparoendoscopic single-site surgery (LESS) has gained popularity in urology over the last few years.

Objective

To report a large multi-institutional worldwide series of LESS in urology.

Design, setting, and participants

Consecutive cases of LESS done between August 2007 and November 2010 at 18 participating institutions were included in this retrospective analysis.

Intervention

Each group performed a variety of LESS procedures according to its own protocols, entry criteria, and techniques.

Measurements

Demographic data, main perioperative outcome parameters, and information related to the surgical technique were gathered and analyzed. Conversions to reduced-port laparoscopy, conventional laparoscopy, or open surgery were evaluated, as were intraoperative and postoperative complications.

Results and limitations

Overall, 1076 patients were included in the analysis. The most common procedures were extirpative or ablative operations in the upper urinary tract. The da Vinci robot was used to operate on 143 patients (13%). A single-port technique was most commonly used and the umbilicus represented the most common access site. Overall, operative time was 160 ± 93 min and estimated blood loss was 148 ± 234 ml. Skin incision length at closure was 3.5 ± 1.5 cm. Mean hospital stay was 3.6 ± 2.7 d with a visual analog pain score at discharge of 1.5 ± 1.4. An additional port was used in 23% of cases. The overall conversion rate was 20.8%; 15.8% of patients were converted to reduced-port laparoscopy, 4% to conventional laparoscopy/robotic surgery, and 1% to open surgery. The intraoperative complication rate was 3.3%. Postoperative complications, mostly low grade, were encountered in 9.5% of cases.

Conclusions

This study provides a global view of the evolution of LESS in the field of minimally invasive urologic surgery. A broad range of procedures have been effectively performed, primarily in the academic setting, within diverse health care systems around the world. Since LESS is performed by experienced laparoscopic surgeons, the risk of complications remains low when stringent patient-selection criteria are applied.     

单孔腹腔镜猪动物训练模型的建立体会

目的介绍用猪作单孔腹腔镜泌尿外科手术动物模型的经验与体会。方法对20头健康小型猪以氯胺酮、戊巴比妥钠麻醉,应用单孔多通道（Triport）腹腔镜穿刺器（Olympus）或自制单通道穿刺器建立通道,利用可弯曲操作器械（钳、剪）,开展单孔腹腔镜肾切除术、肾部分切除术、肾固定术、输尿管切开取石、输尿管离断吻合、输尿管膀胱吻合术、膀胱切开取石术,每头猪双侧脏器均行相应手术。记录术中、术后并发症的发生情况,以及遇到的技术难题。结果用20头猪共开展各种单孔腹腔镜手术260例次,其中肾切除术40例次,成功率85.0%（34/40）;肾部分切除术40例次,成功率80.0%（32/40）;肾固定术40例次,成功率95.0%（38/40）;输尿管切开取石40例次,成功率85.0%（34/40）;输尿管离断吻合术40例次,成功率82.5%（33/40）;输尿管膀胱吻合术40例次,成功率87.5%（35/40）;膀胱切开取石术20例次,成功率100%（20/20）。结论使用单孔多通道（Triport）腹腔镜穿刺器或自制单通道穿刺器在猪体内建立单孔腹腔镜泌尿外科动物模型是可行、有效的,可以为临床医师提供良好的训练机会。     

Laparoendoscopic single-site radical nephrectomy for localized renal cancer: a descriptive research study with at least a 10-year follow-up

BackgroundLaparoendoscopic single-site (LESS) surgery is performed to further narrow the incisions and reduce tissue injury. It has been more than10 years since the surgery was first described. However, there is still no report on the results of 10-year follow-up. This study evaluated the use of long-term oncology and the renal outcomes of LESS radical nephrectomy (LESS-RN) in the treatment of localized renal cancer.MethodsWe retrospectively analyzed the clinical data of patients treated with LESS-RN at Changhai Hospital from 2009 to 2012. Patients with localized kidney cancer who were followed-up for at least 10 years were included in the study. The baseline data and major perioperative outcome variables were analyzed. Overall survival (OS) and cancer-specific survival (CSS) were calculated using the Kaplan-Meier method.ResultsA total of 48 patients were included in the study, which had a median follow-up of 11 years (interquartile range, 10.7–11.8 years). The 10-year OS and CSS rates were 87.5% [42/48; 95% confidence interval (CI): 0.778–0.972] and 97.9% (47/48; 95% CI: 0.937–1.021), respectively. At the most recent follow-up, there were 5 patients with a chronic kidney disease stage ≥3. Among these 5 patients, 3 developed uremia and required continuous dialysis.ConclusionsFor localized renal cancer, LESS-RN is safe and effective with excellent long-term oncology controllability and good functional outcomes. Prospective studies with large sample sizes need to be conducted to validate our results.     

Laparoendoscopic single-site and conventional laparoscopic radical nephrectomy result in equivalent surgical trauma: preliminary results of a single-centre retrospective controlled study

Background

Laparoendoscopic single-site surgery (LESS) has been developed in an attempt to further reduce the morbidity and scarring associated with surgical intervention, and it has been proposed to result in less induced surgical trauma than conventional laparoscopy.

Objective

Investigate the surgical trauma after LESS radical nephrectomy (LESS-RN) and laparoscopic radical nephrectomy (LRN).

Design, setting, and participants

This was a retrospective single-centre study including 66 patients: 31 patients underwent LESS-RN and 35 historical control patients who had undergone LRN. LRNs were performed between April 2008 and May 2009; LESS-RNs were performed between May 2009 and February 2011.

Intervention

LESS-RN and LRN were both performed via a transperitoneal access. Blood samples were collected pre- and intraoperatively at 6, 24, and 48 h, and at 5 d postoperatively.

Measurements

Serum concentrations of acute-phase markers, C-reactive protein (CRP), serum amyloid A (SAA) antibody, and interleukin 6 (IL-6) and interleukin 10 (IL-10) were measured at each time point by enzyme-linked immunosorbent assay. Clinical data were collected by reviewing the patient's records.

Results and limitations

There were no differences in serum CRP and SAA levels between the groups (CRP: p = 0.12; SAA: p = 0.09) at all time points. The changes in IL-6 levels in the LRN group were statistically significantly higher compared with the LESS-RN group at 6 h after surgery (p = 0.02), whereas the LESS-RN group showed statistically significantly higher IL-6 levels than the LRN group at 24 h after surgery (p = 0.02).Also, the serum levels of the anti-inflammatory cytokine IL-10 showed different kinetics in each group, being higher in the LESS-RN during the early postoperative phase (at 6 h: p = 0.01) and higher in the LRN group at 48 h after surgery (p = 0.01). The limitations of this study were its nonrandomized character and the small cohort of patients.

Conclusions

LESS-RN is as effective as LRN without compromising surgical and postoperative outcomes, but it does not add any significant advantage in comparison with traditional LRN in terms of systemic stress response and surgical trauma.     

Current surgical technique and outcomes of laparoendoscopic single-site adrenalectomy

In this paper, we describe the surgical technique, summarize the outcomes of comparative studies, and provide updates on other advanced surgeries in laparoendoscopic single-site (LESS) adrenalectomy. A systemic literature search in the PubMed databases was performed to identify all publications related to LESS adrenalectomy. LESS adrenalectomy performed using transumbilical, transperitoneal subcostal, or retroperitoneal approaches has been demonstrated to be a safe and feasible alternative to conventional laparoscopic adrenalectomy. Its advantages include shorter hospital stay and less pain, although the longer operative time is a concern. Additional well-designed randomized control trials are required. Furthermore, LESS partial adrenalectomy and robotic-assisted single-port adrenalectomy may be the development trends of the future.