腹腔镜保留脾脏胰体尾切除术解剖技巧及手术体会

目的 探讨腹腔镜保留脾脏胰体尾切除术（laparoscopic spleen-preserving distal pancreatectomy，LSPDP）的技术要点，分析Kimura法保留脾脏的胰体尾切除术中解剖技巧及手术体会。方法 回顾性分析2013年1月至2017年8月皖南医学院第一附属医院肝胆外科采用LSPDP治疗胰体尾部良性肿瘤及部分交界性肿瘤15例患者的病例资料。结果 2例因术中出血难以控制结扎脾血管行脾切除术；2例因术中无法判断肿块部位行中转开腹，术中B超定位；其余11例均行完全腹腔镜下保脾胰体尾切除术。平均肿块最大直径（2.8±1.1）cm，手术时间150～437 min，中位时间M（P25，P75）] 240（180，270）min，平均术中失血量（313.3±51.3）mL，平均术后住院时间（9.3±2.9）d，平均术后排气时间（2.8±1.9）d，首次进食流质平均时间（3.8±1.9）d。术后4例发生胰漏，其中A级胰漏1例，经保守治疗后好转；B级胰漏3例，经抗感染、抑酶、持续腹腔冲洗后好转，带管出院2例，分别于术后24 d、30 d拔除引流管。15例术后随访9个月至5年，2例术后6个月内复发，分别于6、9个月死亡。3例随访6个月出现胃肠道症状（主要表现为食欲差、进食后呕吐）；余10例术后情况良好。结论 术前精确的影像学评估、术中精细的解剖联合可靠的腹腔镜止血器械，LSPDP治疗胰腺体尾部良性肿瘤及部分交界性肿瘤是安全、可行的。对LSPDP术中出血进行有效预防，手术才能够安全顺利进行。

Anatomic skills and experience on laparoscopic spleen-preserving distal pancreatectomy

Objective To discuss the anatomic skills and experience on laparoscopic spleen-preserving distalpancreatectomy (LSPDP) by Kimura technique. Methods Clinical data of 15 patients with benign and partialborderline tumor of pancreatic body and tail who treated by LSPDP method from Jan. 2013 to Aug. 2017 inthe First Affiliated Hospital of Wannan Medical College was analyzed retrospectively. Results Splenic vesselsin 2 patients were ligated and the spleen were removed due to intraoperative hemorrhage difficult to control.Two patients received open laparotomy and were located by B-ultrasonic due to the inability to determine thelocation of the lump in laparoscopy. All the remaining 11 cases received complete LSPDP, the mean lump sizewas (2.8±1.1) cm, the operation time was 150~457 min, the median operation time M(P25, P75)] was 240 (180,270) min, mean blood loss was (313.3±51.3) mL, mean postoperative hospitalization time was (9.3±2.9) days,mean postoperative gastrointestinal function recovery time was (2.8±1.9) d, the time to eat liquid food first was(3.8±1.9) d. Complications were observed in 4 patients, 1 case with A-grade pancreatic fistula was improvedafter conservative treatment; 3 cases with B-grade pancreatic fistula were improved after anti-infective therapy,inhibition of enzymes and continual negative pressure drainage, 2 cases were discharged with drainage tube, andtheir drainage tubes was removed respectively on the 24th day and 30th day after surgery. Fifteen patients werefollowed-up for 9 months to 5 years. Among them, recurrence occurred in 2 cases at 6 months after surgery, deathoccurred at 6 months and 9 months later respectively. Gastrointestinal symptoms occurred in 3 cases at 6 monthsof follow-up (mainly due to poor appetite and vomiting after eating). In addition, 10 patients were in good conditions, 13 patients didn’t recurred. Conclusion Preoperative accurate image evaluation and intraoperativefine anatomy with reliable hemostatic laparoscopic instrument, LSPDP is safe and feasible in the treatment ofbenign and partial borderline tumors of pancreatic body and tail. Safe and successful LSPDP procedure dependson effective prevention of intraoperative blood loss in during operation