螺旋CT肾动脉成像在腹腔镜肾部分切除术中的应用

目的：探讨术前肾血管CT血管成像（CTA）在指导腹腔镜下肾部分切除术中血管处理的作用。方法：15例患者中肾癌9例,肾错构瘤6例。术前均行。肾血管CTA。经腹膜后入路施行腹腔镜肾部分切除术,术中根据CTA提示寻找并阻断肾动脉。结果：CTA示肾门前肾动脉分支3例,占总病例数20％。副肾动脉1例,占总病例数6．7％。术中探查均发现CTA所提示的异常血管,探查未发现其他异常动脉。本组15例全部手术成功。结论：CTA能清楚显示血管的解剖及变异,为术中处理肾动脉提供有效的指导。     

后腹腔镜肾切除术肾蒂血管处理技巧

目的:探讨后腹腔镜肾切除术肾蒂血管的处理技巧。方法:2010年1月至2018年4月由同一术者为329例患者行腹膜后入路腹腔镜肾切除术,根据肾蒂血管处理方式分为非同步组(n=175)与同步组(n=154),均采用3孔法施术,经腹膜后入路,显露肾蒂,非同步组采用先处理肾动脉的方法,游离肾脏,最后结扎肾静脉。同步组先游离出肾动脉及肾静脉并结扎,最后游离肾脏。巨大肾积水者,先吸出部分积液,以利显露肾蒂。对比分析两组手术时间、术中失血量。结果:两组手术均顺利完成。非同步组与同步组手术时间分别为(101.7±36.9)min与(121.9±39.1)min,术中失血量分别为(83.3±63.9)mL与(115.3±43.2)mL,两组手术时间、术中出血量差异有统计学意义(P<0.05)。结论:后腹腔镜肾切除术的关键是肾蒂血管的处理,术中灵活选择手术步骤、非同步处理肾脏动静脉有助于减少术中出血,缩短手术时间,增加手术安全性。     

腹腔镜肾切除术中钛夹处理肾蒂的体会

目的:介绍腹腔镜肾切除术中单纯采用钛夹处理肾蒂的术式与经验。方法:腹腔镜肾切除术7例,其中肾积水无功能肾6例,肾结核1例。经腹腔镜操作,分离出输尿管显露肾蒂,肾动脉、肾静脉钛夹夹闭后切断,单纯采用钛夹处理肾蒂切除肾脏。结果:手术均获成功,术中和术后无肾血管出血发生。手术时间130~220m in,平均150m in;术中出血80~150m l,平均120m l;术后住院时间5~7d。结论:腹腔镜肾切除术中单纯采用钛夹处理肾蒂,效果确切,经济可行。     

孤立肾肾肿瘤外科保肾治疗策略的选择及初步探讨

目的:探讨孤立肾肾肿瘤保肾治疗策略的选择。方法:回顾本中心2017年2月—2022年3月收治孤立肾肾肿瘤患者41例,男28例,女13例,年龄59(27～79)岁。其中38例为体检或术后复查中发现,2例患者因血尿就诊,1例患者因腰腹部肿块就诊。肿瘤位于左肾14例,右肾27例,其中肾门部肿瘤2例,肿瘤直径24(8～75) mm。所有患者均在气管插管全麻下进行,其中4例行开放肾部分切除术,19例行腹腔镜肾部分切除术,11例行机器人辅助腹腔镜肾部分切除术,3例行小切口辅助腹腔镜肾部分切除术,4例行腹腔镜肾肿瘤微波消融术。记录手术时间、出血量、肾动脉阻断方式、肾动脉阻断时间、术中及术后并发症、术前及出院前血肌酐值、住院时间。结果:所有手术均安全顺利完成,无术中并发症发生,2例腹腔镜肾部分切除术采用分支动脉阻断,其余肾部分切除术均采用肾动脉主干阻断,腹腔镜肾肿瘤微波消融术均无阻断。2例患者出现术后并发症。开放肾部分切除术组、腹腔镜肾部分切除术组、机器人肾部分切除术组、小切口辅助腹腔镜肾部分切除术组及腹腔镜微波消融组中位手术时间(173 min vs 135 min vs 120 min vs 26...     

孤立肾巨大肿瘤保留肾单位的手术治疗

目的：探讨孤立。肾巨大肿瘤的诊治方法。方法：对2例孤立肾肾肿瘤直径≥8．0cm的患者,先行腹腔镜手术游离肾脏血管,再行开放手术将。肾肿瘤剜除。结果：2例手术均获成功,1例术后发生肾功能不全,1例完全康复,术后随访12个月,肿瘤均无复发或转移。结论：对于孤立。肾巨大肿瘤,术前行肾动脉血管检查、肾肿瘤超选择性栓塞,术中运用腹腔镜游离肾血管、开放手术冷缺血阻断肾动脉,使肿瘤与正常肾组织分界清楚、减少出血、加快手术操作、有助于保护患者肾功能,提高患者生活质量。     

Hem-o-lok结扎夹在腹腔镜肾切除肾蒂处理中的应用

目的:探讨腹腔镜肾切除术中用Hem-o-lok结扎夹处理肾蒂的方法、优势及其应用价值.方法:2004年1月～2006年9月行腹腔镜肾切除术56例,其中38例术中应用Hem-o-lok夹处理肾蒂血管,包括腹腔镜单纯肾切除9例,腹腔镜.肾癌根治术18例,腹腔镜肾输尿管全长切除术11例.观察手术时间、术中出血量、是否中转开放、术后胃肠功能恢复时间、术后住院时间以及术后并发症等情况.结果:应用Hem-o-lok夹处理肾蒂的38例腹腔镜肾切除手术均获成功,无一例转为开放手术,术中术后无肾血管出血及其他严重并发症.手术时间35～270 min,平均165 min;术中出血量50～600 ml,平均187 ml;术后胃肠道功能恢复时间18～72 h,平均32h;术后住院时间7～16天,平均11天.结论:在腹腔镜.肾切除术中,Hem-o-lok结扎夹可以安全快速可靠的处理肾蒂血管,是一种新型有效的血管控制系统,具有广阔的应用前景.     

后腹腔镜术切除无功能积水肾的疗效观察

目的：探讨后腹腔镜下切除无功能积水肾的可行性和安全性及规避手术风险的方法。方法：对62例积水无功能肾患者行后腹腔镜积水无功能肾切除术。术前常规行肾脏CT平扫及增强检奄。利用PACS系统仔细阅片,了解肾动脉分支及走向。然后建立腹膜后腔隙,参照解剖标志充分显露。肾蒂血管,用Hem-o—lok夹闭肾蒂血管后切断,分离切除患肾,留置腹膜后引流管,并统计手术时间、术中m血量和术中术后并发症,观察手术效果。结果：62例患者手术均获得成功,手术时间为50～180min,平均为130min。术中出血10～100m1．平均37ml。术中损伤腹膜3例,胸膜1例,未发现血管损伤、腹腔脏器损伤等并发症。引流管于术后2～3天拔除,术后住院5～10天,平均6．5天。结论：后腹腔镜下积水无功能肾切除术安全可行,术中通过辨认解剖标志结扎肾蒂血管和沿正确的平面游离患肾是手术成功的关键。     

Hem-o-lok结扎夹在腹腔镜肾切除肾动脉处理失败（附4例报告）

目的：报告Hem—o—lok结扎夹在腹腔镜肾切除术中肾动脉处理失败的体会。方法：报告我院4例经后腹腔途径行腹腔镜肾切除术时Hem—o—lok结扎夹结扎肾动脉时动脉断裂出血的临床资料。男3例,女1例。平均年龄76岁（58～84岁）。肾透明细胞癌2级2例,。肾透明细胞癌1～2级1例,肾盂移行细胞癌1例。行腹腔镜肾癌根治术3例,腹腔镜肾输尿管全长切除术1例。4例均经后腹腔途径行腹腔镜肾切除术,采用Hem—o—lok结扎夹结扎肾动脉和肾静脉。结果：3例Hem—o—lok结扎夹结扎。肾动脉后,肾动脉结扎处近心端发生部分断裂出血,1例肾动静脉结扎切断后肾脏已完全游离在取肾脏标本时肾动脉完全断裂引起大出血。4例均改行开放手术,血管阻断钳部分阻断腹主动脉,可吸收线缝合血管断端。平均手术时间80min（65～110min）,术中平均出血量450ml（200～1000m1）,1例术中输血800ml。结论：腹腔镜肾切除时Hem-o-lok结扎夹结扎肾动脉具有一定的潜在危险,肾动脉一旦断裂需及时改行开放手术。     

腹腔镜下选择性肾段动脉阻断肾部分切除术疗效评价

目的探讨腹腔镜下节段性肾动脉阻断肾部分切除术治疗肾肿瘤的方法及疗效。方法选取肾肿瘤患者11例,术前行CTA检查了解肾动脉情况。术中游离肾动脉主干、二级甚至三级肾动脉,选择性阻断肿瘤所在部位分级肾动脉,实施腹腔镜下肾部分切除术。结果 9例（81.8%）一次成功,2例转肾动脉主干阻断,手术时间70-200min,平均130min;术中出血量20-400ml,平均50ml。术后肾功能正常,本组无并发症。术后随访4-18个月,所有患者情况良好,复查CT等相关检查未见肿瘤复发或远处转移。结论临床分期T1a及T1b期、单发的肾肿瘤采用腹腔镜下节段性肾动脉阻断肾部分切除能有效地保护肾功能。     

后腹腔镜下肾切除应用威克外科结扎锁处理肾动静脉可靠性分析

目的:探讨后腹腔镜下肾切除应用威克外科结扎锁处理肾脏动静脉的可靠性.方法:124例后腹腔镜肾切除,采用腰部3个Trocar(2个10 mm,1个5 mm),由腹膜外人路.根据肾动脉搏动找到并分离出肾动脉,游离肾动脉至适当长度,用13 mm威克外科结扎锁(Hem-o-lok,Week Closure Systems)处理肾动脉,肾动脉近心端以2枚夹闭,远心端以1枚夹闭.切断肾动脉,同法处理肾静脉.结果:124例均顺利完成手术,动静脉处理过程顺利、安全,所有病例均用威克外科结扎锁处理完成,无结扎锁滑脱现象,术中及术后未出现继发性出血,术中出血10～100 ml,平均45 ml,均未输血,术后平均住院日6.5天.结论:后腹腔镜肾切除应用威克外科结扎锁处理肾脏动静脉安全、可靠、经济、操作方便.     

Hem-o-lok结扎锁在后腹腔镜肾切除术肾蒂血管处理中的应用

目的:探讨后腹腔镜肾切除术中应用Hem-o-lok结扎锁处理肾蒂血管的价值。方法:我们为63例患者行后腹腔镜肾切除术并采用Hem-o-lok结扎锁处理肾蒂血管,其中肾动脉近端用大号Hem-o-lok2枚结扎,远端用2枚钛夹夹闭后剪断,肾静脉用加大号Hem-o-lok近端2枚、远端1枚结扎后剪断。结果:本组手术时间90~255min,平均135min;出血量20~180ml,平均45ml;术后住院时间5~8d;术中肾蒂血管处理满意,术中、术后未发生严重并发症。结论:腹腔镜肾切除术中用Hem-o-lok结扎锁分别处理肾动静脉,安全可靠,经济实用,值得临床推广应用。     

PlasmaKinetic bipolar vessel sealing: burst pressures and thermal spread in an animal model

BACKGROUND AND PURPOSE: Laparoscopic bipolar instruments are commonly employed to cauterize and divide tissue. A next-generation bipolar device has been developed that employs vapor pulse coagulation energy. We assessed the vessel-sealing capability of this device and quantified thermal spread during application. MATERIALS AND METHODS: Bilateral laparoscopic nephrectomy was performed on six common swine >25 kg. Five-millimeter clips and surgical staplers (US Surgical, Norwalk, CT) were utilized to perform nephrectomy on one side, while the Gyrus PlasmaKinetic bipolar device (Minneapolis, MN) was employed for the contralateral nephrectomy. Vessel-sealing capabilities were assessed via burst-pressure studies. The extent of thermal spread was measured after tissue fixation and hematoxylin and eosin staining. RESULTS: Surgical clips/vascular staplers adequately controlled/sealed renal hilar vessels with burst pressures nearing 300 mm Hg. The Gyrus bipolar device reliably sealed and divided renal arteries 相似文献   

Laparoscopic Procurement of Kidneys with Multiple Renal Arteries is Associated with Increased Ureteral Complications in the Recipient

This study investigates the effect of renal artery multiplicity on donor and recipient outcomes after laparoscopic donor nephrectomy. Three-hundred and sixty-one sequential procedures were performed over a 4-year period. Forty-nine involved accessory renal arteries; of these, 36 required revascularization and 13 were small polar vessels and ligated. The 312 remaining kidneys with single arteries served as controls. Study variables included operative times, blood loss, hospital stay, graft function and donor and recipient complications. Kidneys with multiple revascularized arteries had a longer mean warm ischemia time (35.3 vs. 29.2 min, p = 0.0003), and more ureteral complications (6/36 vs. 10/312, p = 0.0013) than single-artery controls. In contrast, ligation of a small superior accessory artery had no significant effect on donor operative time, blood loss, or complication rate while providing similar recipient graft function compared to single-artery controls. Renal artery number is important in selecting the appropriate kidney for laparoscopic procurement. Given the current excellent results with right-sided donor nephrectomy, kidneys with single arteries should be preferentially procured, irrespective of side.     

Management of renal allografts with multiple renal arteries resulting from laparoscopic living donor nephrectomy

Laparoscopic living donor nephrectomy (LLDN) has become an accepted procedure in many transplant centers. The placement of laparoscopic vascular staples can result in multiple short, small-caliber renal arteries that the recipient surgeon must deal with to restore perfusion to all parts of the kidney. The incidence of multiple renal arteries resulting from LLDN, surgical management of multiple renal arteries, and the short- and long-term graft functions were studied in 73 consecutive kidney recipients at a single center. Various techniques used for reconstruction are described, including the use of recipient internal iliac artery for the extension and reconstruction of small-caliber, short renal vessels. Single-artery allografts were compared with those with multiple arteries, with length of renal artery, warm ischemia time, hospital length of stay, operating time, creatinine levels, and 1 yr survival rates not found to be significantly different. The presence of multiple renal arteries should not exclude the possibility of using the left kidney for LLDN.     

Renal Hilus Ligation With Single Stapler in Laparoscopic Donor Nephrectomy

BackgroundLigation of renal hilus is the most important stage of laparoscopic donor nephrectomy. Laparoscopic staplers are securely used for renal pedicle control. We present our donor nephrectomy cases in which we used 1 stapler for renal artery and vein ligation.MethodsDemographic data, number of arteries and veins, ligation types, operation time, and complication rates are recorded.ResultsOne hundred twenty laparoscopic donor nephrectomy cases who were operated between December 2017 and August 2018 in İstinye University Hospital and İstanbul Aydın University Hospital were retrospectively evaluated. All of the operations were done by 2 surgeons with a fully laparoscopic method. None of the cases were converted to open nephrectomy. There was 1 renal artery in 110 (91.7%) cases, 2 renal arteries in 9 (7.5%) cases, and 3 arteries in 1 (0.8%) case. Renal artery and vein were ligated with single stapler in 115 (95.8%) cases. Double stapler was used in 5 (4.2%) patients. There were no major complications for donors and no implantation problems for grafts.DiscussionLaparoscopic donor nephrectomy is the most used technique for living donor operations. Vascular stapler is securely used for renal artery and vein ligation with high costs. Two or, due to the number of vessels, sometimes 3 staplers are used in the standard technique. In our study, the operation was finished securely in 95.8% of the patients with single stapler use. Single stapler use for ligating renal hilus is safe in kidneys even with suitable multiple arteries and veins in laparoscopic donor nephrectomy.     

Laparoscopic renal autotransplantation

BACKGROUND AND PURPOSE: Renal autotransplantation is an extensive open surgical operation consisting of two distinct procedures, live-donor nephrectomy and autotransplantation, and requiring two large skin incisions. Herein, we analyze the feasibility of performing the entire procedure laparoscopically. MATERIALS AND METHODS: Renal autotransplantation was performed entirely laparoscopically in six female farm pigs. Following a left donor nephrectomy, intracorporeal renal hypothermia was achieved by intra-arterial perfusion of ice-cold solution through a 4F balloon catheter. During autotransplantation, the renal vessels were anastomosed intracorporeally to the previously prepared ipsilateral common iliac vessels in an end-to-side fashion. Laparoscopic freehand suturing (5-0 Prolene) and knot-tying techniques were employed exclusively. A staged contralateral native nephrectomy was performed in five animals. Postoperative follow-up included serial creatinine measurements, intravenous urography, aortography, and renal histologic examination. RESULTS: The mean operating time was 6.2 hours (range 5.3-7.9 hours), the venous anastomosis time was 33 minutes (range 22-46 minutes), the arterial anastomosis time was 31 minutes (range 27-35 minutes), and the total iliac clamping time was 77 minutes (range 62-88 minutes). The total renal ischemia time was 68.7 minutes: warm ischemia 5.1 minutes, cold ischemia 33 minutes and rewarming 31 minutes. Serum creatinine concentrations remained stable: baseline 1.3 mg/dL, after autotransplantation 1.1 mg/dL, and after contralateral nephrectomy 1.6 mg/dL. Intravenous urography and aortography prior to euthanasia (N = 5) demonstrated prompt contrast uptake and excretion by the autotransplanted kidneys and patent arterial anastomoses, respectively. Histopathologic examination of the autograft demonstrated normal renal architecture. CONCLUSIONS: Renal autotransplantation can be performed utilizing laparoscopic techniques exclusively. This study may form the basis for performance of complex urologic vascular procedures laparoscopically.     

HELICAL COMPUTERIZED TOMOGRAPHY ARTERIOGRAPHY FOR EVALUATION OF LIVE RENAL DONORS UNDERGOING LAPAROSCOPIC NEPHRECTOMY

PURPOSE: Traditionally, live renal donors are evaluated with excretory urography and renal arteriography. Helical computerized tomography (CT) arteriography offers a less invasive alternative for demonstrating necessary anatomical information before laparoscopic allograft harvest. We evaluate the accuracy of helical CT arteriography in depicting renal vascular anatomy with an emphasis on the detection of arterial and venous anomalies. MATERIALS AND METHODS: Imaging studies were done on 175 patients according to a standard CT arteriography protocol with early arterial phase scanning (14 to 20-second delay), and 1 mm. axial and 3-dimensional maximum intensity projection reconstructions. Renal vascular anatomy was mapped with attention to aberrant arterial and venous anatomy. Intraoperative findings were correlated at laparoscopic donor nephrectomy. RESULTS: There was overall agreement between CT arteriography and laparoscopic findings in 163 cases (93%). Supernumerary renal arteries were identified in 40 cases (23%). Sensitivity, specificity and accuracy of CT arteriography for arterial anatomy were 91, 98 and 96%, respectively. Cases with less than 2 mm. accessory arteries or early branching single vessels simulating dual arteries were misdiagnosed. Venous anomalies occurred in 11 patients (6.3%). Sensitivity, specificity and accuracy of CT arteriography for venous anatomy were 65, 100, and 97%, respectively. Misdiagnoses included early venous bifurcations and supernumerary tributary veins, which were poorly opacified. CONCLUSIONS: Helical CT is highly accurate and specific for the demonstration of renal arterial anatomy. Poor opacification resulted in a lower sensitivity for venous anatomy. Overall, helical CT provides essential anatomical information, and is an alternative to standard urography and arteriography.     

Laparoscopic nephrectomy in patients with renal vein and/or inferior vena cava anomalies: Video presentation

Abstract:   Laparoscopic nephrectomy is a standard surgery for the treatment of many types of renal tumor, renal pelvic tumor, and benign disease. Renal vein and inferior vena cava anomalies are not uncommon, having been detected at an incidence of 2–17%. With the increasing number of patients undergoing laparoscopic nephrectomy, surgeons have more opportunities to encounter major anomalies of the renal vein and inferior vena cava. This video presents images of the management of the renal pedicle in laparoscopic nephrectomy in cases where there were anomalies of the renal vein and inferior vena cava.
Patient 1 had left renal tumor with the left inferior vena cava, patient 2 had left ureteral tumor with double inferior vena cava, patient 3 had left renal tumor with double inferior vena cava and a circumaortic renal vein, patient 4 had left renal tumor with a retro-aortic renal vein, and patient 5 had left renal tumor with a circumaortic renal vein. Multiple renal arteries were present in patients 3, 4, and 5.
In laparoscopic nephrectomy complicated by anomalies of the renal vein and inferior vena cava, (i) surgical staff should be alert for the potential presence of aberrant veins and multiple renal arteries that may not be visualized in preoperative imaging. (ii) An anterior transperitoneal approach is well-suited in the understanding of positional relationships of vessels and anatomical landmarks in cases of vascular anomalies. (iii) With recent advances in diagnostic imaging modalities, such as multislice computed tomography (CT) and 3-D CT, it has become easier to identify the major arterial and venous anomalies. However, intraoperative observation and assessment remain important and mandatory in the management of smaller anomalous vessels accompanied by major anomalies.     

Use of Hem-o-lok clips effectively lengthens renal vein during laparoscopic live donor nephrectomy

We retrospectively reviewed our last 12 laparoscopic donor nephrectomies (LDNs) in which both the renal artery and the renal vein were controlled using 2 Hem-o-lok clips (Weck Closure Systems, Research Triangle Park, NC, United States) on the proximal sides and the vessels were divided without securing the graft-side vessels (group 1). We compared the results with our 12 immediately preceding LDN donors in whom the arteries were controlled with 3 endoclips and the veins were controlled with staplers (group 2). The length of the vein was significantly longer (approximately 4 mm difference) in group 1, mainly due to trimmed staples from the graft vessels. Both cohorts of donors had uneventful surgery with no complications, and all the recipients recovered smoothly without any delayed graft function. Average operation time and warm ischemia time were similar among both groups (189 vs 207 minutes; 168 vs 149 seconds, respectively; both P > .1). We conclude that the use of Hem-o-lok effectively lengthens graft renal veins and is less costly during LDN.     

Pedicular vascular control in laparoscopic living donor nephrectomy: The use of clips instead of stapler in 341 donors

PURPOSE: To demonstrate a less expensive approach for laparoscopic donor nephrectomy. MATERIALS AND METHODS: Left donor nephrectomy was done transperitoneally in flank position. Renal vein and artery were exposed and prepared for nephrectomy. Nondisposable trocars and instruments were used. The adrenal vein was clipped and its arteries were bipolar coagulated. Both renal artery and vein were clip-ligated using three medium large nonautomatic metallic clips and divided, instead of using rather expensive vascular endostapler. Kidney was hand-extracted from suprapubic incision (no Endobag was used). RESULTS: Donor nephrectomy was performed in 341 donors. Mean warm ischemia time was 8.17 minutes. Mean operative time was 260.3 minutes. Conversion and reoperation was required in 2.1% and 3.8% of donors, respectively. Ureteral complications were observed in 2.1% of recipients. No vascular accident occurred from pedicular vessels. One-year graft survival in recipients was 92.6%. By this approach, at least $600 was saved in each nephrectomy. CONCLUSION: Laparoscopic donor nephrectomy can be performed with a less expensive setup without adverse effects on graft outcome. Vascular control using nonautomatic clips instead of more costly vascular endostapler and also hand extraction of the kidney is safe, practical, and economical.