超声刀在腹腔镜直肠全系膜切除术中的临床应用

目的探讨超声刀在腹腔镜直肠全系膜切除术（Total mesorectal excision，TME）的临床应用价值。方法我院自2004年8月～2007年5月。应用超声刀在腹腔镜下对33例直肠癌患者实施TME术。结果33例患者手术顺利，无中转开腹，手术时间115～320min，平均155min；术中出血10～100ml，平均50ml；术后1～2d恢复胃肠功能并下床活动。住院时间5—14d，平均8d。术中及术后无并发症发生。术后随访1月至3年，无复发。结论应用超声刀行腹腔镜TME术，保肛率高，创伤小，出血少，烟雾少。术后恢复快，是一极具应用前景的微创外科新技术。     

腹腔镜与传统开腹术治疗直肠癌的手术并发症比较

目的 分析腹腔镜下全系膜切除术（TME）与开腹TME手术治疗直肠癌在并发症发生率方面的差别。方法 回顾43例腹腔镜和50例传统开腹手术治疗直肠癌患者的临床资料，分析并发症的发生原因及其发生率。结果 腹腔镜治疗组较传统阡腹组在术后肠功能恢复、早期下床活动、住院时间等方面均占优势。在术中损伤．吻合口瘘、术后性功能保护、排尿功能障碍、局部复发和切口转移上与传统开腹组均无明显差别。结论 腹腔镜下TME治疗直肠癌的效果同传统开腹术，术后患者自觉症状较开腹手术良好。     

腹腔镜下低位直肠癌经腹会阴联合切除术25例分析

目的探讨腹腔镜下经腹会阴联合切除术治疗低位直肠癌的应用价值。方法按照肠道肿瘤切除的TME原则和开腹手术的无瘤操作原则,利用腹腔镜技术对25例低位直肠癌患者实施TME腹会阴联合切除术。结果 25例患者均手术顺利。手术时间平均125min,术中出血平均80mL;术后1～2d恢复胃肠功能并下床活动,平均住院6d。结论应用腹腔镜技术进行腹会阴联合切除术治疗低位直肠癌安全可行,能完全达到TME要求和无瘤操作原则,具有创伤小、术后疼痛轻、恢复快等优点。     

腹腔镜直肠癌Miles根治术12例的体会

目的 :探讨经腹腔镜直肠癌Miles根治术的临床应用。方法 :回顾分析 12例低位直肠癌 ,利用腹腔镜超声刀技术行直肠全系膜切除 (totalmesorectalexcision ,TME)Miles根治术 ,并对手术操作、术后恢复等情况进行临床分析。结果 :12例患者均顺利完成手术 ,手术时间 110～ 16 0分钟 ,平均 12 5分钟 ,术中出血 80～ 16 0ml,平均 12 0ml ;12例直肠系膜均完整 ;术后 2～ 3d恢复胃肠功能并下床活动 ,住院时间 7～ 9d ,平均8 2d。无因手术及术后并发症而死亡的病例。结论 :用腹腔镜方法行低位直肠癌Miles根治术 ,不仅可达到开腹根治术的目的 ,而且具备操作安全、微创、恢复快等优点。     

腹腔镜辅助直肠全系膜切除术治疗低位直肠癌76例回顾性分析

目的　探讨腹腔镜辅助直肠全系膜切除术治疗低位直肠癌的可行性及临床疗效。方法　选取 1 998年 2月～ 2 0 0 3年 6月本院行腹腔镜直肠全系膜切除术的低位或超低位直肠癌病人 ,收集手术、术后病理学结果及术后并发症和恢复情况的临床资料 ,进行分析和讨论。结果　共有 76例接受腹腔镜直肠全系膜切除术。平均手术时间为 1 78.6± 4 9.9min(90～ 35 0min) ,术中平均出血量为 77.4ml(1 0～ 6 0 0ml) ,术后平均住院天数为 1 7.7± 1 2 .0d(6～ 6 7d) ,肠道功能恢复的时间平均为2 .8d。肿块距下切端平均为 3.35 2± 1 .0 6 2cm(2 .0～ 5 .0cm )。术后并发症发生率为 1 8.4 %。无手术死亡率。中转开腹手术 7例 (9.2 1 % )。总保肛率为 6 3.1 6 %。结论　腹腔镜直肠全系膜切除术能够达到和符合TME的原则 ,治疗低位、超低位直肠癌是可行的     

腹腔镜下直肠癌全系膜切除拖出式吻合8例报告

目的探讨腹腔镜下直肠癌全系膜切除术(total mesorectal excision,TME)的优势及拖出式吻合的使用价值。方法2005年11月~2006年12月对8例直肠癌行腹腔镜下直肠癌TME,经肛门拖出切除并手工吻合。结果8例均完全在腹腔镜下完成全系膜游离后拖出肛门外切除并手工吻合,无辅助切口。手术时间180~300min,平均220min。8例随访8~18个月,平均13个月,未发现穿刺口种植和局部复发。结论腹腔镜下完成全系膜游离,清晰完整,拖出肛门外切除、吻合直观、简便、经济。     

超声止血刀在腹腔镜全直肠系膜切除低位、超低位及结-肛吻合术中的作用

目的探索应用超声刀在腹腔镜下进行全直肠系膜切除(TME)低位、超低位及结-肛吻合术治疗下段直肠癌的可行性.方法按TME原则,应用超声刀在腹腔镜下对30例低位直肠癌患者实施TME低位、超低位或结-肛吻合术,对其中3例合并慢性萎缩性胆囊炎、胆囊结石患者,同时实施了腹腔镜胆囊切除术; 1例合并卵巢囊肿蒂扭转、胆囊结石患者,同时切除了病变胆囊和卵巢囊肿.结果 30例患者手术顺利,无中转开腹,手术时间115～320 min,平均155 min; 术中出血5～80 ml,平均20 ml; 术后1～2天恢复胃肠功能并下床活动,住院时间5～14天,平均8天.术后疼痛剂应用14例,术中及术后无并发症发生.结论应用超声刀行腹腔镜TME低位、超低位或结-肛吻合术,保肛率高,创伤小,出血少,烟雾少,术后疼痛轻,恢复快,是一极具应用前景的微创外科新技术.     

腹腔镜直肠全系膜切除术

目的探讨腹腔镜外科技术在直肠全系膜切除术(TME)的应用。方法对39例腹腔镜直肠全系膜切除术患者进行随访和回顾性分析。结果腹腔镜直肠前切除术30例,中转手术1例;腹腔镜辅助Miles手术9例。无手术死亡,术中盆底静脉丛破裂出血1例(发生率2.6%)。平均手术时间185min,平均出血量85ml,平均术后住院日为8.5d。术后发生吻合口瘘1例,尿潴留1例。39例患者术后随访1～28个月,仅1例DukesC1期的低分化腺癌患者,术后12个月盆腔局部肿瘤复发。全组患者的trocar穿刺孔及腹壁切口无肿瘤种植。结论腹腔镜直肠全系膜切除术创伤小、疼痛轻、恢复快。只要严格掌握手术适应证,正确应用腹腔镜技术就能完成此类手术。     

经肛门拖出标本的全腹腔镜直肠癌全系膜切除术

目的探讨腹腔镜直肠癌全系膜切除术中切除标本自肛门内拖出的可行性。方法 2007年1月~2010年5月,对30例肿块5 cm的直肠癌施行全腹腔镜直肠癌全系膜切除术,手术标本自肛门拖出,肠断端腔镜下荷包缝合及管型吻合器结直肠吻合。结果 30例在腹腔镜下顺利完成手术,无中转开腹。无腹腔、盆腔脏器的损伤。手术时间120~240min,平均150 min;术中出血20~80 ml,平均35 ml。发生吻合口漏4例,均经保守治疗治愈(18~30 d)。术后随访3~40个月,平均24.3月,2例1年后吻合口复发。结论直径5 cm的标本自肛门拖出的全腹腔镜直肠癌全系膜切除术是可行的,避免腹部辅助切口,创伤更小。     

腹腔镜直肠癌直肠全系膜切除保肛手术的临床应用

目的 探索腹腔镜下行直肠癌直肠全系膜切除（TME）保肛手术的可行性。方法 对2年余住院的54例直肠癌患者文施在腹腔镜下行TME保肛于术。54例中51例在腹腔镜下完成手术，包括前切除14例，低位前切除（吻合门距离齿状线2．0cm以上）19例，超低位前切除（吻合口与齿状线的距离小于2．0cm）16例，结肠-肛管吻合（吻合口位于齿状线）2例。3例中转开腹；其中2例因Dukes C期肿瘤已浸润肠管周围，1例因骨盆狭小，肿瘤距肛缘7cm．腹腔镜下操作困难而中转开腹。结果 51例腹腔下TME的患者手术顺利。手术时间110～210（平均145）min；术中出血30～80（平均50）mL；术后48～36h恢复胃肠功能并下床活动，住院时间7～14（平均9）d。术后应用止痛剂20例。术中术后均无并发症发生．术后控便功能的恢复旧吻合口高低而存在差异．6个月后均恢复正常排便功能。51例术后均随访，随访时间为6～36个月。均尤操作孔种植和肿瘤复发。结论 腹腔镜直肠癌TME保肛手术安全可行，其创伤小、出血少、术后恢复快，是极具应用前景的微创新技术。     

腹腔镜下直肠癌全直肠系膜切除术

目的 探讨腹腔镜下行直肠癌全直肠系膜切除根治术的临床效果。方法 对38例直肠腺癌患者采用腹腔镜下联合应用超声刀循盆筋膜壁层和脏层的间隙行锐性游离全直肠系膜,切除一个不间断的直肠整体标本,并对全组病例随访2年余。结果 38例患者手术顺利,无中转开腹,术后排便、排气时间平均为32h,术后平均住院天数为7．5d。术后随访至今,38例患者均无腹部穿刺口种植,其中2例出现局部复发(1例伴肝转移)。38例患者均无排尿困难,6例患者有性功能减退。结论 腹腔镜下行直肠癌全直肠系膜切除术手术既能有效降低术后局部复发率和保护盆腔自主神经功能,又具有微创优点,值得临床推广。     

腹腔镜辅助下的结肠直肠手术

目的 :探讨腹腔镜在结直肠手术中的应用。方法 :腹腔镜下为 2例直肠中下段癌行全直肠系膜切除 ,为 1例乙状结肠癌行乙状结肠癌根治术 ,为 1例结肠肝曲肿瘤行手助腹腔镜结肠肝曲肿瘤切除术。结果 :4例手术均获成功 ,无死亡病例 ,无并发症发生 ,手术平均 16 0min ,平均失血 4 0ml(10～ 10 0ml)。结论 :腹腔镜辅助下的结直肠手术是安全和可行的     

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目的：探讨直肠全系膜切除在预防直肠癌术后肿瘤局部复发中的作用以及同该操作相关的一些问题。方法：对1998年8月以来共75例直肠癌术中行全直肠系膜切除的疗效和并发症等进行分析。结果：全组无手术死亡，术后吻合口漏4例，发生率为10％(4／40)；吻合口狭窄2例，发生率为3．3％(2／21)；会阴切口感染2例，发生率为14．3％(2／14)；术后肿瘤局部复发1例，复发率为1．3％。结论：直肠癌术中全直肠系膜切除能有效预防和降低直肠癌术后的局部复发率，但该操作给病人带来的不利因素也不容忽视。     

Factors that influence the adequacy of total mesorectal excision for rectal cancer

OBJECTIVE: In 1997 with the start of CRO7 trial it was agreed that adequacy of surgical resection of rectal cancer would be determined by a pathologically determined grading of the mesorectum the so called total mesorectal excision score (TME score). Scores ranged from 1-3 with 3 being a perfect specimen. The aim of this study was to investigate factors which may influence TME scores and establish if local recurrence is related to them. METHOD: Data on all patients undergoing resectional surgery for rectal cancer in our unit are entered prospectively onto a database. Pathology reports of those patients who underwent total mesorectal excision were examined and the TME scores added to the database. Categorical variables were analysed using the chi2 test, continuous variables using ANOVA. Statistical significance was taken as P < 0.05. RESULTS: Between January 2000 and June 2005, 518 patients underwent surgery for adenocarcinoma of the rectum, of these, 287 patients had a total mesorectal excision for mid or lower third tumours under the care of seven colorectal surgeons. All resected specimens were scored by a Consultant GI pathologist. Two hundred and fourteen patients underwent anterior resection and 73 underwent abdomino-perineal resection. The median age of the patients was 73 years (range 38-95 years). One hundred and ninety-four patients were male. Seventy-eight patients were treated with preoperative radiotherapy, 59 short course and 19 long course. TME scores were TME1 n = 30, TME2 n = 99, TME3 n = 158. Fifteen patients developed local pelvic recurrence at 2 years. Total mesorectal excision scores were not statistically influenced by Dukes' stage, width of tumour, preoperative radiotherapy or grade of surgeon. Male patients were statistically more likely to have a TME score of 2 or 3 compared with female P = 0.04. Patients undergoing an anterior resection were statistically more likely to have a TME score of 2 or 3 compared with abdomino-perineal resection P = 0.0001.Tumours with a circumferential resection margin (CRM) of more than 1 mm were more likely to have a TME score of 2 or 3 score (P = 0.0001). There was no relationship between TME and local recurrence (P = 0.966). CONCLUSION: There is no relationship between the TME score in patients undergoing resectional surgery for adenocarcinoma of the rectum and the development of local recurrence at 2 years. Other factors such as CRM involvement are more likely to have an impact on local recurrence. The factors that influence the quality of TME are the operative procedure of anterior resection, male gender and CRM positivity. There appear to be no deleterious effects on the TME score by Specialist Registrars performing the operation under Consultant supervision. While TME scores may be an index of a technical performance, they appear to have little role in predicting future outcomes.     

全直肠系膜切除术治疗低位直肠癌疗效观察

目的探讨全直肠系膜切除术（TME）对低位直肠癌的治疗价值.方法119例直肠癌患者,肿瘤距肛缘均在8 cm以内.54例应用传统手术方法治疗（传统组）,65例应用TME治疗（TME组）.对两组患者的平均手术时间、术中失血量、住院天数和局部复发率进行比较.结果TME组平均手术时间为118 min,术中失血量100mL,而传统组则为182min,340mL,差异有统计学意义（均P＜0.05）;两组局部复发率分别为9.23%和35.18%（P＜0.01）.住院天数无明显差异.结论应用TME治疗低位直肠癌,手术时间短,出血少,局部复发率低,是治疗低位直肠癌的首选术式.     

Bladder and sexual dysfunction after mesorectal excision for rectal cancer

BACKGROUND: Urinary and sexual dysfunction are recognized complications of rectal excision for cancer. The aim of this study was to examine the frequency of such complications after mesorectal excision, shortly after this method was introduced. METHODS: Spontaneous flowmetry, residual volume of urine measurement and urodynamic examination, including cystometry and simultaneous detrusor pressure and urinary flow recording, was carried out before and 3 months after curative rectal excision. Urinary symptoms and sexual function were evaluated by means of questionnaires before and after operation. Each patient served as his or her own control. RESULTS: Forty-nine consecutive patients, 39 of whom had a total mesorectal excision (TME) and ten a partial mesorectal excision, were examined before surgery and 35 again after operation. In two patients, a weak detrusor was detected before operation. Two patients developed signs of bladder denervation after operation. Transitory moderate urinary incontinence appeared in four other women. Six of 24 men reported some reduction in erectile function and one became impotent. Two men reported retrograde ejaculation. All the complications were seen in the TME group. CONCLUSION: Mesorectal excision for rectal cancer resulted in a low frequency of serious bladder and sexual dysfunction.     

腹腔镜下应用超声刀行胆总管囊肿切除术

目的：探讨腹腔镜下应用超声刀行胆总管囊肿切除、肝管空肠Roux—Y吻合术的操作技术及优越性。方法：本组45例患儿在腹腔镜下应用超声刀行胆总管囊肿切除,胆道重建术。首先在腹腔镜监视下行胆囊穿刺造影,切除胆囊。然后用超声刀横断囊肿,近端游离至肝总管处切断,远端游离至胰胆管汇合处结扎切断,彻底切除囊肿壁。经脐部2cm切口提出空肠于腹壁外行空肠Roux-Y吻合,肝支30～35cm,然后将肠管送回腹腔经结肠后将肝支拉至肝下,将肝管与空肠端侧吻合。结果：45例患儿均在腹腔镜下应用超声刀完成胆总管囊肿切除、肝管空肠Roux—Y吻合术。手术时间3．5～6．0h(平均4．2h)。术中出血量10～50ml(平均15ml)。全部患儿无术中并发症。术后住院时间3～9d(平均5．5d)。38例获随访,随访时间1个月～1．5年,无吻合口狭窄及粘连性肠梗阻发生,肝功能检查正常。结论腹腔镜下应用超声刀行胆总管囊肿切除、肝管空肠Roux—Y吻合术安全可靠。优点为手术视野清晰,解剖层次清楚,术中出血少、创伤小,术后疼痛轻、切口小,手术瘢痕不明显。     

Safety and Feasibility of Laparoscopic Intersphincteric Resection for Very Low Rectal Cancer

Background

Laparoscopic surgery has been reported to be one of the approaches for total mesorectal excision (TME) in rectal cancer surgery. Intersphincteric resection (ISR) has been reported as a promising method for sphincter-preserving operation in selected patients with very low rectal cancer.

Methods

From July 2005 to December 2008, 35 patients with very low rectal cancer underwent laparoscopic TME with ISR. The results were compared retrospectively with those of previous open TME with ISR.

Results

Conversion to open surgery was necessary in one (3%) patient. The median operation time was 293 min and median estimated blood loss was 40 ml. The pelvic plexus was completely preserved in 32 patients. There was no mortality. Postoperative complications occurred in three (9%) patients. The median length of postoperative hospital stay was 17 days. Macroscopic complete mesorectal excision was achieved in all cases. Complete resection (R0) was achieved in 34 patients. Clinical lymph node stage, operation time, and blood loss were significantly different between the laparoscopic group and open group, but the differences of other factors were not statistically significant.

Conclusions

Laparoscopic TME with ISR is technically feasible and a safe alternative to laparotomy with favorable short-term postoperative outcomes.     

全直肠系膜切除术治疗直肠癌的近远期临床疗效观察

目的探究全直肠系膜切除术治疗直肠癌的近远期临床效果。方法采用随机数字法将2011年5月至2013年2月期间收治的64例直肠癌患者分成传统术式组和系膜切除术组(每组各32例患者),其中传统术式组患者的手术方案为传统术式治疗直肠癌,系膜切除术组患者的手术方案为全直肠系膜切除术治疗直肠癌。采用SPSS 18.0统计软件进行统计分析,两组患者在手术时间、术中出血量、住院时间及胃肠道功能恢复时间的计量资料采用均数±标准差(±s)表示,组间比较用独立样本t检验;并发症发生率、癌症复发率及3年生存率的计数资料采用χ2检验,检验水准为0.05。结果在手术时间、术中出血量、住院时间及胃肠道功能恢复时间方面传统术式组患者分别为(175.5±57.6)min、(134.7±40.5)ml、(15.1±4.8)d、(87.1±23.5)h;系膜切除术组分别为(125.6±40.1)min、(91.2±34.9)ml、(9.4±4.1)d、(50.6±18.3)h,两组差异均具有统计学意义(P0.05);传统术式组患者的并发症发生率为25.00%(8/32),系膜切除术组患者的并发症发生率为6.25%(2/32),两组差异具有统计学意义(χ2=4.27,P0.05);传统术式组患者的癌症复发率及3年生存率分别为18.75%、65.63%,系膜切除术组患者的癌症复发率及3年生存率分别为3.13%、93.75%,两组差异均具有统计学意义(χ2=4.01、7.81,P0.05)。结论全直肠系膜切除术治疗直肠癌具有良好的近远期临床疗效,可以减少手术、住院时间及术中出血量,能降低并发症发生率及癌症复发率,提高患者的生存率,适合临床推广。