手辅助腹腔镜下活体供肾摘取术的手术配合

目的探讨手辅助腹腔镜下活体供肾摘取术的手术配合方法。方法对2例供者实施手辅助腹腔镜下供肾摘取术。结果2例均取左肾,手术均获成功,手术时间分别为70和80 m in,2例供肾热缺血时间分别为165和195 s,失血100~200 m l。移植肾功能良好。结论手辅助腹腔镜下取肾可使供者的手术创伤减轻,住院时间缩短,身体恢复快。准确、熟练、默契的手术配合对顺利完成该手术有着重要的意义。     

综合治疗屈光不正性弱视患儿的护理

对40例弱视患儿采用验光配镜后进行遮盖疗法及弱视治疗仪训练等综合治疗及护理.结果总有效率达95.0%.提出心理护理、掌握治疗时机、及时矫正屈光不正性弱视、综合弱视训练、坚持治疗和随访对治疗患儿屈光不正性弱视起着重要作用.     

经腹腔手辅助腹腔镜活体供肾摘取术

目的：介绍经腹腔手辅助腹腔镜活体供肾摘取术（HLDN）。方法：供肾者5例，行经腹腔的手辅助腹腔镜活体供肾摘取术，总结手术方法。结果：平均手术时间116min，供肾平均热缺血时间2．8min，平均供肾动脉长度1．8cm，平均供肾静脉长度2．7cm。未发生任何手术并发症。术后7d供者恢复出院，3例受者术后第3－12天血肌酐恢复正常，2例受者发生肾功能延迟恢复（DGF）。结论：HLDN结合了单纯腹腔镜供肾摘取术（LDN）和开放供肾摘取术（ODN）的优点。既有切口小，痛苦小和恢复快的微创手术特点，又减少了单纯腹腔镜器械操作的难度，使外科医师更易掌握，显著缩短了手术时间和供肾热缺血时间，保证了供肾质量；同时有利于迅速处理一些紧急情况，减少并发症，提高了供者安全性和手术成功率。     

2例后腹腔镜亲属活体供肾切除及肾移植病人的护理

总结2例后腹腔镜活体供肾及肾移植的术前准备及术后观察要点.结果除1例穿刺口周围皮下气肿外,无其它并发症发生.认为后腹腔镜活体供肾取肾术是一种微创、安全的手术方式.术前做好对供者的心理辅导和安全评价,术后严格记录尿量,加强生命体征的监测和引流物的观察对帮助供者康复尤为重要.     

68例腹腔镜活体供肾切取术的临床研究

目的:总结68例腹腔镜活体供肾切取术(laparoscopic live donor nephrectomy,LDN)的临床经验。方法:回顾分析2004年5月至2008年4月我院施行的LDN68例的临床资料,对手术时间,供肾热缺血时间,术中失血量,肾动、静脉长度进行统计,并对数据按照取左、右肾进行分组比较。根据改良的Clavien分级系统对围手术期并发症情况进行分析。术后对供者血肌酐(SCr),肾小球滤过率(GFR),24h尿蛋白定量水平,血压水平以及受者的肾功能情况进行随访。结果:68例LDN手术均取得成功,手术时间为(87.5±7.8)min,供肾热缺血时间为(85.6±13.1)s,术中失血量为(56.8±8.5)ml,肾动脉长度为(3.0±0.3)cm,肾静脉长度为(2.3±0.3)cm,按照取左右肾手术时间分别为(89.5±8.4)min和(86.8±7.2)min(P>0.05),供肾热缺血时间为(86.7±12.3)s和(85.2±14.1)s(P>0.05),术中失血量为(58.2±10.2)ml和(55.4±9.4)ml,(P>0.05),肾动脉长度为(2.5±0.3)cm和(3.5±0.3)cm(P<0.0001),肾静脉长度为(3.2±0.4)cm和(1.6±0.3)cm(P<0.0001)。围手术期3例(4.4%)出现并发症,其中Grade2b级1例,Grade1级2例。肾移植手术均获成功,受者在1周内肾功恢复正常,1例受者术后6个月并发肺部感染死亡。供者术后SCr,24h尿蛋白定量水平,GFR值维持在正常范围内,无新发高血压患者出现。结论:LDN安全、微创,完善LDN操作技术,加强对供者术后随访十分重要。     

无气腹悬吊腹腔镜活体供者取肾术与开放手术的比较

目的：评价无气腹悬吊腹腔镜活体供者取肾手术（SGLLDN）的临床价值。方法：比较40例SGLLDN和32例开放活体供者取肾手术（OLDN）的临床效果。结果：SGLLDN组39例成功,转开放手术1例;OLDN组32例全部成功。SGLLDN与OLDN相比,切口长度较短,（8.0±2.3）cm vs（19.5±3.5）cm（P〈0.01）;手术时间较长,（120.1±16.2）min vs（60.5±12.1）min（P〈0.05）;术中出血量较少,（158.5±45.3）mL vs（289.2±65.1）mL（P〈0.01）;住院时间较短,分别（5.0±1.0）d vs（9.0±2.0）d（P〈0.05）;术中供肾热缺血时间和术后肾功能恢复正常时间二者差异无统计学意义（P〉0.05）。结论：与OLDN相比,SGLDN具有切口创伤小、出血少、患者恢复快、住院时间短等优点。缺点是手术时间稍长、费用稍贵。临床可根据不同供者要求选择不同手术方法。     

经腹膜后入路腹腔镜活体供肾切取技术的改良及效果观察

目的 对经腹膜后入路腹腔镜活体供肾切取技术进行改良,并观察其临床效果.方法 回顾分析2009年7月至2012年6月间41例采用改良的经腹膜后入路腹腔镜技术切取供肾的临床资料.改进的方法包括:(1)肾脏游离采用钝性分离加剪刀锐性分离,超声刀间断止血的联合方法进行 ;(2)肾动、静脉及输尿管充分游离完毕后,在侧腹部自Trocar套管孔向下做平行腹直肌切口约5～6 cm长,沿肌纤维走行方向分别钝性分离牵开腹外斜肌、腹内斜肌和腹横肌,进入腹膜后腔.术者左手经此切口进入腹膜后腔,重新建立气腹 ;(3)直视下经Trocar套管置入活检枪,在术者固定供肾情况下穿刺获得“零点”活检样本 ;(4)术者左手适度牵拉肾动、静脉,依次在肾动、静脉近心端用2枚Hem-o-lock夹夹闭,剪刀离断肾动、静脉后直接取出供肾.结果 41例供肾切取术均获成功,无中转开放手术.手术耗时65～130 min,平均85 min,供肾热缺血时间58～110 s,平均78 s,供肾动脉长2.1～3.7 cm,平均2.9 cm,供肾静脉长2.5～4.1 cm,平均3.5 cm.术中出血量15～80 ml,平均28ml.供者术后住院时间4～7 d,平均4.8d.41例均获得“零点”活检供肾穿刺样本.除2例发生轻微淋巴漏外,未发生其他手术并发症.41例受者移植肾功能恢复顺利,未出现移植肾功能恢复延迟.结论 改良的经腹膜后入路腹腔镜供肾切取技术安全、有效,能进一步保护移植肾功能和减少供者的损伤程度.     

经腹膜后入路腹腔镜活体供肾切取术中肾动脉结扎方式的临床经验分析

目的 对经腹膜后入路腹腔镜活体供肾切取术(LDN)中肾动脉的结扎方式进行分析总结.方法 2003年6月至2012年6月共实施亲属活体肾移植术211例,其中2007年以后136例供肾切取均采用经腹膜后入路的腹腔镜活体供肾切取手术.在LDN肾动脉结扎中,采取开放Hem-o-lock夹结扎40例,腹腔镜下Hem-o-lock夹结扎87例,腹腔镜下ENDO-GIA结扎5例,腹腔镜下Hem-o-lock夹结扎联合手辅助丝线缝扎4例.结果 开放行Hem-o-lock夹结扎方式供肾热缺血时间最短,为(1.1±0.3) min,腹腔镜下Hem-o-lock夹结扎方式供肾热缺血时间最长,为(3.2±0.8)min,开放组与其他各组相比,供肾热缺血时间的差异均有统计学意义(P＜0.05).在移植肾预后各因素的比较中,各组无明显差异.腹腔镜下单纯Hem-o-lock夹结扎中出现Hem-o-lock夹致肾动脉破裂1例,经紧急转为开放手术,持续输血和自体回输并积极维持生命体征等应急措施,供者最终于术成功,顺利出院.其余结扎方式均安全可靠,未出现不良反应.结论 LDN中,开放行Hem-o-lock夹结扎方式的供肾热缺血时间最短,而腹腔镜下Endo-GIA结扎方式和Hem-o-lock夹联合手辅助丝线缝扎方式最为安全可靠 ;针对供肾可疑有严重动脉粥样硬化等高危人群的LDN,Hem-o-lock夹对肾动脉的结扎需谨慎.     

自制单孔设备经腹膜后入路腹腔镜活体供肾切取11例体会

目的 探讨用自制单孔设备行经腹膜后入路腹腔镜亲属活体供肾切取术的安全性和可行性.方法 2011年1月到2012年6月间采用自制单孔多通道设备及常规腹腔镜操作器械,先后完成11例经腹膜后入路腹腔镜亲属活体供肾切取手术.结果 供肾均为左肾,平均手术时间为149.5 min,术中出血量为20～350 ml,供肾热缺血时间为2～4 min.供者术后5～6 d出院,未发生手术并发症.结论 采用自制单孔多通道设备完成经腹膜后入路腹腔镜活体供肾切取术在技术上是可行的 ;与传统腹腔镜供肾切取手术相比,手术创伤小,恢复快.     

经腹膜后入路腹腔镜活体右侧供肾切取术中肾蒂的处理

目的 探讨后腹腔镜活体右侧供肾切取术的肾蒂处理方法及其安全性、临床效果.方法 2009年1月至2012年5月共实施后腹腔镜活体右侧供肾切取62例.回顾性分析供者的一般状况、术中出血量、供肾热缺血时间、手术时间、供肾血管长度、供者住院时间、并发症等.结果 62例供者手术均获得成功,无中转开放手术,无明显术后并发症.受者手术顺利,移植肾功能恢复良好.供者手术时间为(73.5±10.4)min,术中出血量为(30.7±10.4)ml,住院时间为(5.2±1.6)d.供肾热缺血时间为(107.2±24.8)s,腔静脉切口缝合时间为(2.0±0.5)min,供肾动、静脉长度分别为(3.3±0.5)cm和(2.0±0.4)cm.结论 应用后腹腔镜技术结合开放取肾通道处理肾蒂的方法切取带有腔静脉瓣的右侧肾脏,既保证了供者、供肾的安全性,又使受者手术更易顺利进行,取得了良好的临床效果.     

Living Donor Renal Transplantation Using Grafts With Multiple Arteries Procured by Laparoscopic Nephrectomy

Objective

Kidney grafts with multiple renal arteries (MRAs) are not uncommon, but they do make transplantation more difficult. Laparoscopic graft nephrectomy has become the standard; however, the safety and reliability must be maintained for both a donor and a recipient even in case of MRAs. This study evaluated the short-term outcomes of living donor renal transplant using grafts with MRAs procured by laparoscopic nephrectomy.

Patients and Methods

This study reviewed all living donor kidney transplantations performed from January 2008 to June 2009, which were divided into 3 groups according to the number of renal graft arteries. The serum creatinine level, warm ischemic time (WIT), rewarming time, total ischemic time (TIT), operative time, acute rejection episodes, and complications in each group were evaluated.

Results

The serum creatinine level showed no difference among the groups. Longer TIT was observed in the MRAs group, but WIT and rewarming time did not differ. The acute rejection rate was not different. There were no vessel complications in any donors and recipients.

Conclusion

Harvesting kidney grafts with MRAs by laparoscopic nephrectomy requires a longer TIT; however, transplantation can be performed safely and reliably for both donors and recipients.     

手助腹腔镜根治性肾肿瘤切除术患者的围术期护理

目的 探讨手助腹腔镜根治性肾肿瘤切除术患者围术期的护理方法.方法 对36例肾肿瘤根治性切除术患者充分做好术前各项准备,术后密切观察生命体征变化,加强呼吸道管理和切口渗液的观察,及时予以健康教育指导.结果 36例手术均获成功,手术时间65～220 min,平均:105.0 min;术中出血20～200 ml,平均85.0 ml.无并发症发生.随访1～3年,无1例复发和转移.结论 加强围术期护理,可减少并发症发生,有利于患者术后早期康复.     

手助腹腔镜根治性肾肿瘤切除术患者的围术期护理

目的 探讨手助腹腔镜根治性肾肿瘤切除术患者围术的护理方法。方法 对36例肾肿瘤根治性切除术患者充分做好术前各项准备，术后密切观察生命体征变化，加强呼吸道管理和切口渗液的观察，及时予以健康教育指导。结果 36例手术均获成功，手术时间65～220min，平均105．0min；术中出血20～200ml，平均85．0ml。无并发症发生。随访1～3年，无1例复发和转移。结论 加强围术期护理，可减少并发症发生，有利于患者术后早期康复。     

Change in Renal Function After Laparoscopic Donor Nephrectomy for Kidney Transplantation

Background

Laparoscopic donor nephrectomy (LDN) has become the method of choice for living-donor kidney transplantation. However, LDN may result in decreased renal function in the donor, and risk of end-stage renal failure has been reported.

Objective

To evaluate changes in renal function after LDN.

Patients and Methods

The study included 51 living donors of renal transplants between March 2002 and December 2008. Before kidney donation, we computed the initial function of the kidney preserved in the donor using 24-hour creatinine clearance (Ccr) and functional ratio as revealed at technetium 99m dimercaptosuccinic acid renal scanning. After kidney donation, serum creatinine concentration (sCr) and Ccr were calculated on postoperative day 2 and every 3 months thereafter.

Results

After LDN, mean sCr increased immediately, from 0.90 to 1.31, as did Ccr of the kidney preserved in the donor, from 58.2 to 79.6, a 36.9% increase. A greater percent increase in function was observed in younger donors and those with lower initial Ccr of the preserved kidney. Although 9.8% of donors demonstrated slightly decreased renal function of the preserved kidney at last follow-up, renal function was adequately preserved in most donors.

Conclusion

Younger donors and those with lower initial function of the preserved kidney before nephrectomy demonstrate a greater increase in function after nephrectomy. Age might be a risk factor for decreased renal function after LDN. Older potential living donors may need more careful evaluation before kidney donation.     

Laparoscopic Versus Open Renal Procurement for Pediatric Recipients of Living Donor Renal Transplantation

Despite reports demonstrating the safety of laparoscopic donor nephrectomy (LDN) for pediatric recipients of renal transplants, recent evidence has challenged using LDN for recipients 5 years of age or younger. We retrospectively reviewed the records of all pediatric recipients of living donor renal transplants from September 2000 through August 2004. We compared those who received allografts recovered by LDN (n = 34) with those recovered by open donor nephrectomy (ODN, n = 26). Outcomes of interest included operative complications, postoperative renal function, the incidence of delayed graft function or episodes of acute rejection and long-term graft function. Donor and recipient demographic data were similar for the LDN and ODN groups. Serum creatinine and calculated creatinine clearance were not significantly different between groups both in the early postoperative period and at long-term follow-up (p > 0.142). Rates of delayed graft function and acute rejection did not differ between groups. Among recipients aged 5 years old or younger stratified by donor technique (9 LDN, 5 ODN recipients), no difference was noted in graft outcomes both early and long-term (p > 0.079). At our center, pediatric LDN recipients have graft outcomes comparable to those of ODN recipients. At experienced centers, we recommend continued use of LDN for pediatric recipients of all ages.     

Laparoscopic Living Donor Hepatectomy for Pediatric Liver Transplantation

Living donor liver transplantation is a well established modality, especially for pediatric transplantation with excellent early graft function and long-term results. Left lateral sectionectomy through open approach is a well-standardized procedure. Considering our acquired experience in both laparoscopic liver resection and standard open surgery for live donation in pediatric and adult patients, we decided to offer, for the first time in Belgium, a laparoscopic approach for the left lateral sectionectomy to a young mother. The patient was a child 6-months old, affected by biliary atresia and rapidly deteriorating while waiting on a deceased donor liver graft. Surgical technique and key-points of this procedure in the living donor are hereby discussed.