单孔后腹腔镜解剖性肾上腺切除术5例报告

目的：初步探讨单孔后腹腔镜肾上腺切除术的临床可行性和安全性。方法：2009年7～8月采用单孔后腹腔镜肾上腺切除术治疗肾上腺肿瘤患者5例,其中男性患者2例,女性患者3例,平均年龄（58．4±3．6）岁,平均体重指数（25．9±2．6）;左侧3例,右侧2例;肾上腺皮质无功能腺瘤3例,肾上腺醛固酮瘤2例。行肾上腺全切术1例,肾上腺肿瘤切除术4例。3例患者术后留置引流管,2例患者未留置引流管结果：5例单孔后腹腔镜肾上腺切除术均顺利完成,手术时间35～60min,平均（51．2±11．2）min;肿瘤最大径1．0～3．5cm,估计出血量5～10ml,平均（8．0±2．7）ml,无中转开放及转为标准三孔腹腔镜手术,术中发生1例腹膜破裂,给予修补,无其他并发症发生,短期随访无术后并发症发生。结论：初步结果显示了单孔后腹腔镜肾上腺切除术具有良好的安全性和可行性,但其临床治疗效果尚需大样本中远期随访和对照研究予以证实。     

腹腔镜肾上腺巨大肿瘤切除术临床分析

目的:探讨腹腔镜肾上腺巨大肿瘤切除术的临床可行性及意义。方法:应用经腹腔途径为45例肾上腺肿瘤患者行腹腔镜肾上腺肿瘤切除术。术前均经B超、CT或MRI等相关影像学检查初步确诊。45例患者分为2组,32例肾上腺肿瘤直径5cm(A组),13例肿瘤直径5cm(B组)。观察2组患者手术时间、术中出血量、住院时间、中转开放率及围手术期并发症等情况。术后常规随访,定期行B超及胸片检查。结果:45例均顺利完成腹腔镜手术,平均手术时间(A组58.6min,B组86.7min)、术中平均出血(A组31.6ml,B组84.3ml)两组差异均有统计学意义(P0.01);中转开放手术A组3例(9%),B组1例(8%),两组差异无统计学意义(P0.05)。B组术中1例需输血;术后平均住院A组5.2d,B组5.7d,两组差异无统计学意义(P0.05)。术后患者均顺利康复。结论:与腹腔镜较小肾上腺肿瘤(5cm)切除术相比,腹腔镜巨大肾上腺肿瘤(5cm)切除术手术时间长,术中出血多,但住院时间及围手术期并发症无显著差异。只要术者具备娴熟的腹腔镜操作技巧及充分的临床经验,腹腔镜较大肾上腺肿瘤切除术切实可行。     

后腹腔镜肾上腺肿瘤切除术

目的：探讨后腹腔镜切除肾上腺肿瘤手术的应用价值及腹膜后腔建立方法的改进。方法：回顾性分析我院2003年10月～2006年3月采用后腹腔镜手术治疗102例肾上腺肿瘤患者的临床资料,其中肾上腺嗜铬细胞瘤切除29例,原醛症肾上腺腺瘤切除或肾上腺切除52例,皮质醇症肾上腺腺瘤切除21例。结果：102例全部手术成功。手术时间60～130min,平均90min;建立腹腔后间隙时间3～7min,平均4min;术中平均失血量80ml。术后平均住院5天。结论：后腹腔镜手术安全,对患者创伤小,术后肠道功能恢复快,伤121愈合早。新的后腹腔间隙建立方法有效、快捷、方便,值得推广。     

腹膜后腹腔镜肾上腺肿瘤切除术35例报告

目的:总结腹膜后腹腔镜手术治疗肾上腺肿瘤的临床经验。方法:回顾分析2003年5月至2008年12月我院行腹膜后腹腔镜手术治疗肾上腺肿瘤35例患者的临床资料。结果:33例腹腔镜手术成功,2例术中探查为胃肠道肿瘤,中转开放手术。手术时间40~275min,平均(136.2±62.3)min。术中出血20~200ml,平均(91.0±48.2)ml。术后住院5~7d,平均(6.2±0.8)d。发生腹膜损伤2例,瘤体破裂出血1例,Trocar穿刺口脂肪液化3例。结论:用腹腔镜行肾上腺肿瘤切除术具有患者创伤小、术中出血少、术后康复快等优点,但需根据肿瘤大小和病理类型严格掌握,同时应重视局部解剖关系。     

后腹腔镜及手助腹腔镜肾上腺切除术治疗肾上腺肿瘤(附21例报告)

目的 :探讨腹腔镜微创手术治疗肾上腺肿瘤的适应证及手术方法。方法 :对 18例直径小于 6cm的肾上腺肿瘤患者行后腹腔镜肾上腺切除术 (后腹腔镜组 ) ;对 3例最大直径为 10～ 17cm的肾上腺肿瘤患者行手助腹腔镜肾上腺切除术 (手助腹腔镜组 ) ,并观察手术时间、术中出血量、胃肠功能恢复时间和住院时间。结果 :2 1例患者中 ,2 0例成功。其中后腹腔镜组手术时间 2 5～ 135min ,平均 (82 .8± 31.1)min ,术中出血量 6 5～ 16 0ml,平均 (113.4± 31.8)ml,均未输血。手助腹腔镜组手术时间 180～ 2 10min ,术中出血量 80～ 6 0 0ml。两组患者均于术后 2天排气 ,1～ 3天下床活动 ,术后住院 3～ 7天。结论 :与开放手术相比 ,后腹腔镜肾上腺手术具有创伤小、出血少、恢复快等优点 ;手助腹腔镜为巨大肾上腺肿瘤切除提供了微创手术的新方式。     

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。     

后腹腔镜肾上腺肿瘤切除术

1996年 1月～ 2 0 0 1年 5月 ,我科共施行后腹腔镜肾上腺肿瘤切除术 14例 ,其中 13例成功 ,现报告如下。1　资料与方法1.1　一般资料本组 14例 ,男 4例 ,女 10例 ,年龄 2 4～ 66岁 ,平均 40岁。术前根据典型的临床症状 ,血、尿生化检查 ,ＣＴ、磁共振等诊断为肾上腺皮质醇腺瘤 5例 ,嗜铬细胞瘤 3例 ,醛固酮腺瘤 3例 ,无功能性肾上腺皮质腺瘤 3例。左侧 10例 ,右侧 4例。肿瘤大小 1.0ｃｍ× 1.2ｃｍ～ 4.8ｃｍ× 5 .2ｃｍ。1.2　手术方法全麻。患者患侧向上卧位 ,腰部垫枕 ,适当抬高腰桥。作腋前、中、后线标志 ,于腋中线髂嵴上 2ｃｍ处作 2…     

后腹腔镜手术切除巨大肾上腺肿瘤

目的探讨后腹腔镜手术切除巨大（≥6cm）肾上腺肿瘤的可行性。方法2002年6月～2008年6月对30例直径≥6cm巨大肾上腺肿瘤行后腹腔镜切除手术。采用健侧卧位,用自制的气囊扩张后腹腔,分别在腋后线肋缘下、腋中线髂嵴上2cm及腋前线肋缘下穿刺,置入trocar。肿瘤切除后用标本袋取出肿瘤,留置引流管。结果30例后腹腔镜手术成功,无中转开放手术。平均手术时间100min（65～185min）,术中出血量平均80ml（50～250ml）。30例术后随访3～36个月,平均18.5月,无局部复发。结论对于无明显禁忌证的肿瘤,后腹腔镜手术切除巨大肾上腺肿瘤可行、安全,肿瘤直径并不是手术的决定性因素。     

后腹腔镜肾上腺肿瘤切除术疗效观察

目的观察经后腹腔镜肾上腺肿瘤切除术的临床疗效。方法对24例肾上腺肿瘤患者应用后腹腔镜肾上腺肿瘤切除术治疗,观察治疗效果及术后并发症情况。结果本组24例手术均获成功,无中转开放手术。手术时间40~118 min,失血量45~200 m L。无术中及术后输血病例,均未发生感染、肾上腺危象严重并发症。术后住院时间3~9 d,随访6个月,未见复发病例。结论后腹腔镜下手术切除肾上腺肿瘤创伤小、有效率高、恢复时间快。     

腹腔镜下巨大肾上腺肿瘤切除术7例报告

目的：探讨腹腔镜下肾上腺巨大肿瘤（直径≥6 cm）切除术的技术方法和应用价值.方法：7例肾上腺肿瘤患者均行腹腔镜下肾上腺肿瘤切除术,在瘤体表面相对无血管区处切开包膜,沿包膜与瘤体之间迅速分离,切除肿瘤,填塞纱布止血.结果：5例腹腔镜下肾上腺肿瘤切除术顺利完成,1例手助腹腔镜下完成,1例粘连明显转开放手术.平均手术时间120 min;平均术中出血量200 ml.术后1～4天肠功能恢复,3～5天拔除引流管;无明显外科并发症,术后住院平均10天.术后病理诊断嗜铬细胞瘤4例,肾上腺囊肿1例,神经节细胞瘤1例,畸胎瘤1例.术后随访6（3～18）个月,临床症状消失,复查彩超及SCT未见肿瘤复发及恶性变.结论：腹腔镜下肾上腺肿瘤切除术创伤小、恢复快、效果满意,是治疗巨大肾上腺肿瘤的一种理想术式.     

机器人辅助腹腔镜下肾上腺复杂肿瘤手术(附光盘)

目前,传统腹腔镜肾上腺切除术(laparoscopic adrenalectomy,LA)已成为治疗大部分肾上腺肿瘤的首选方法,但其在处理一些复杂性肾上腺肿瘤时仍较困难。达芬奇机器人手术系统在泌尿外科领域的广泛应用和发展是当今世界临床医学发展的里程碑。机器人辅助腹腔镜下肾上腺切除术(robot-assisted laparoscopic adrenalectomy,RALA)使得一些不适合传统腹腔镜手术的肾上腺肿瘤的微创治疗成为可能。本文就达芬奇机器人手术系统、RALA用于复杂肾上腺肿瘤治疗、RALA的手术步骤和技巧做一概述。     

Laparoscopic adrenalectomy in patients with large adrenal tumors

OBJECTIVES: The maximum size of adrenal tumors that should be removed by laparoscopic adrenalectomy is controversial. We conducted a retrospective comparison of the results of laparoscopic adrenalectomy between patients with adrenal tumors > or =6 cm ('large tumors') and patients with adrenal tumors <6 cm ('small tumors'). METHODS: The participants in the study were 16 patients with large tumors and 111 patients with small tumors. The patients comprised 59 men and 68 women (mean age, 49.0 years; age range, 23-79) with varying diagnoses. Of the 16 patients with large tumors, five had Cushing's syndrome, four had pheochromocytomas, six had a non-functional tumor and one had malignant lymphoma. Adrenal tumors were confirmed by hormonal assays, biochemical tests and computed tomography. Of the 16 large tumors, five tumors were on the right and 11 were on the left. RESULTS: We found no significant differences in general demographic parameters between patients with large and small tumors. The mean duration of surgery was not significantly different between two groups. (large tumors, 210 min; small tumors,175 min). The mean volume of blood loss was 212 mL for large tumors and 30 mL for small tumors (P < 0.001, significant difference). There was no significant difference in time until walking, duration of hospitalization or number of using analgesics used. The time to first oral intake of group 1 (<6 cm) was significantly shorter than group 2 (> or =6 cm). Tumor size (> or =7.5 cm) was an independent predictor of a longer operation and greater blood loss in large tumors. CONCLUSIONS: Laparoscopic adrenalectomy for large tumors was safe and minimally invasive.     

腹腔镜肾上腺切除术和开放肾上腺切除术治疗肾上腺巨大良性肿瘤的比较

目的：了解腹腔镜肾上腺切除术（1aparoscopicadrenalectomy,LA）和开放肾上腺切除术（openadre—nalectomy,OA）治疗肾上腺巨大（〉6cm）良性肿瘤的差别。方法：分析2009年1月～2011年12月手术治疗的50例肾上腺巨大良性肿瘤的l陆床特点。其中LA组26例,OA组24例。比较两组年龄、肿瘤大小、手术时间、术中出血量、住院时间、切口长度;LA组嗜铬细胞瘤切除6例,OA组嗜铬细胞瘤切除7例,比较两者术中血流动力学变化。结果：术后病理为肾上腺腺瘤2例,节细胞神经瘤10例,嗜铬细胞瘤13例,髓样脂肪瘤19例,肾上腺囊肿伴出血3例,神经鞘膜瘤2例,肾上腺巨淋巴结增生（Castleman病）1例。LA组和OA组比较,平均年龄分别为（45．3±15．6）岁和（52．2±13．2）岁（P=0．069）;肿瘤直径分别为（7．75±1．26）cm和（8．38±1．96）cm（P=0．098）;平均手术时间分别为（65．2±23．4）min和（126．9±32．5）min（P〈0．01）;出血量分别为（,54．1±19．5）m1和（205．0±49．6）ml（P〈O．01）;住院时间分别为（4．8±1．6）d和（7．6±2．1）d（P〈0．01）;切口长度分别为（7．56±2．06）cm和（18．28±3．25）cm（P〈O．01）。LA组无一例发生手术相关并发症或中转开放;（）A组冈肾血管损伤行一侧肾切除1例。LA组切除嗜铬细胞瘤术中最高收缩压和心率低于OA组（P〈O．05）。术后随访3～26个月,肿瘤无复发。结论：尽管I。A需延长切口取出肿瘤,但与OA相比,切除肾上腺巨大良性肿瘤仍具有手术时间短、出血少、创伤小、恢复快等优势。     

Laparoscopic radical adrenalectomy with adrenal vein tumor thrombectomy: technical considerations

PURPOSE: We describe the technique of adrenal vein tumor thrombectomy during laparoscopic radical adrenalectomy for cancer. MATERIALS AND METHODS: During laparoscopic adrenalectomy for a heterogeneous 7 cm left adrenal mass an adrenal vein thrombus was detected intraoperatively. Laparoscopic ultrasonography was used to delineate precisely the tumor thrombus and its extension into the left main renal vein. The left renal artery and vein were transiently controlled with atraumatic vascular clamps. The renal vein was incised and the intact tumor thrombus was removed en bloc with the radical adrenalectomy specimen. The renal vein was suture repaired with 4-zero prolene and the kidney was revascularized. RESULTS: Renal warm ischemia time was 21 minutes, blood loss was 300 cc and operative time was 6.2 hours. Pathological evaluation revealed a 7.5 cm 68 gm adrenal cortical cancer with tumor thrombus. Soft tissue and adrenal vein margins were negative for cancer. CONCLUSIONS: Laparoscopic radical adrenalectomy with en bloc adrenal vein tumor thrombectomy can be exclusively performed intracorporeally, while respecting oncological principles. Essential technical steps include wide margin excision of the adrenal gland, intraoperative ultrasonography, renal vascular control, en bloc tumor thrombectomy and renal venous suture repair in a bloodless field.     

Technique of anatomical retroperitoneoscopic adrenalectomy with report of 800 cases

PURPOSE: To our knowledge we introduce the technique of anatomical retroperitoneoscopic adrenalectomy. MATERIALS AND METHODS: From February 2000 to October 2005 anatomical retroperitoneoscopic adrenalectomy was performed in 800 consecutive patients with adrenal lesions using a 3 port lateral retroperitoneal approach. After incising Gerota's fascia 3 relatively bloodless planes were entered consecutively to expose and separate the adrenal gland. When entering the first dissection plane between the perirenal fat and anterior renal fascia located at the superomedial side of the kidney, the adrenal could be identified at the initial stage of the operation. The following dissections proceeded in the plane between the posterior renal fascia and the lateral aspect of perirenal fat, and then in the avascular plane located on the parenchymal surface of the upper renal pole. The adrenal vein was dealt with at the final stage. Operative time was defined as the time from skin incision to skin closure. RESULTS: Mean +/- SE operative time was 45 +/- 19.1 minutes (range 25 to 230) and mean estimated blood loss was 25 +/- 10.6 ml (range 5 to 200). Average time to oral intake and ambulation were 1.2 and 1.0 day, respectively. Minor postoperative complications occurred in 12 patients (1.5%). Major complications and perioperative mortality were not observed. The procedures resulted in marked clinical improvements in patients with a hormone secreting tumor, except in 6 with idiopathic adrenal hyperplasia. CONCLUSIONS: Anatomical retroperitoneoscopic adrenalectomy is a safe, effective, technically efficient procedure for surgical adrenal diseases.     

巨大肾上腺肿瘤腹腔镜手术(附光盘)

腹腔镜技术已经成为肾上腺手术的金标准,但对于一些体积巨大的肾上腺肿瘤,腹腔镜手术仍有一定难度,并发症发生率相对较高。经腹腔途径巨大肾上腺肿瘤腹腔镜手术可以减少手术并发症,降低手术难度,本文重点阐述该手术方法和技术要点。     

Experience of retroperitoneoscopic adrenalectomy in 195 patients with primary aldosteronism

OBJECTIVES: Laparoscopic adrenalectomy has become an effective option for aldosteronoma. We evaluated the retroperitoneal approach with regard to safety, efficacy, invasiveness and cost-benefit ratio in patients with primary aldosteronism. METHODS: Between July 1999 and June 2005, we carried out a total of 195 retroperitoneoscopic adrenalectomies (RA) in one hospital, including 108 on the left and 87 on the right, in 78 men and 113 women aged 20-78 years (mean age 48.2 years) with aldosteronoma. Average adrenal tumor size was 16 mm (range 10-32 mm). The 195 operations were divided into 10 groups of 20 operations each, and the mean duration and estimated blood loss for each group were compared. RESULTS: The mean operating time and intraoperative blood loss in RA were 93.2 +/- 37.4 (45-210) min and 68.5 +/- 53.2 (5-210) mL, respectively. Compared to group 1 (cases 1-20), a statistically significant decrease in operative time and estimated blood loss were seen in and after group 4 (>or= case 61, 94.5 +/- 30.3 vs 139.2 +/- 44.7 min, P < 0.01), and in and after group 5 (>or= case 81, 67.5 +/- 50.5 vs 120.5 +/- 60.9 mL, P < 0.01), respectively. No differences were found in duration of surgery and estimated blood loss between left and right sided tumors (P > 0.05). The mean postoperative hospital stay was 4.5 +/- 1.2 days. Postoperative complications, including hematoma and wound infection, occurred in 4.1% of patients. CONCLUSIONS: Retroperitoneoscopic adrenalectomy for aldosteronoma is a safe, effective, and minimally invasive approach with an advantageous cost-benefit ratio. With accumulated experience, it can expedite the learning curve for RA.     

Indications for laparoscopic adrenalectomy for non-functional adrenal tumor with hypertension: Usefulness of adrenocortical scintigraphy

AIM: Laparoscopic adrenalectomy is currently indicated for biochemically and clinically functional adrenal tumors and potentially malignant tumors of the adrenal glands. Non-functional adenomas greater than 5 cm in diameter of the adrenal gland are generally considered to represent potentially malignant tumors. The present study shows indications of laparoscopic adrenalectomy for non-functional adrenal tumors with hypertension in a retrospective fashion. METHODS: Between 1994 and 2004, 110 laparoscopic adrenalectomies were performed at Tokushima University Hospital. All 110 patients underwent detailed endocrinological examination before surgery. Medical and operative records of these 110 patients (57 men, 53 women), including operative parameters, histopathological findings and pre- and postoperative hypertension, were reviewed. Forty-five patients underwent laparoscopic adrenalectomy for non-functional adrenal tumors, and [(131)I]6beta-iodomethyl-19-norcholest-5(10)-en-3beta-ol (NP-59) scintigraphy was performed for patients with preoperative hypertension. RESULTS: Mean patient age was 55.0 years (range, 22-77 years). Mean maximum tumor diameter was 42 mm (range, 20-105 mm). All adrenal tumors were removed successfully by laparoscopic surgery. Hypertension was postoperatively improved in seven of the 11 patients with preoperative hypertension, without subclinical Cushing syndrome. Importantly, all patients who improved hypertension after adrenalectomy displayed strong accumulation in adrenal tumors with visualization of the contralateral gland on NP-59 scintigraphy. Conversely, blood pressure did not improve in four patients for whom scintigraphy yielded negative results. CONCLUSIONS: The indication of laparoscopic adrenalectomy for non-functional adrenal tumors is generally considered for lesions more than 5 cm diameter. However, the present study suggests that laparoscopic surgery should be considered even in patients with tumors less than 5 cm in diameter, if both hypertension and accumulation in tumors on NP-59 scintigraphy are present.