改良胸腔镜下肺动脉成形术在全肺切除术中的应用

目的探讨改良胸腔镜下肺动脉成形术在全肺切除术中应用的可行性。方法2012年4～10月，我科对15例侵犯肺门的肺癌行改良胸腔镜下肺动脉成形联合全肺切除术，与传统方法不同之处在于游离肺静脉、肺动脉及支气管后，在阻断肺动脉时，采用0号不可吸收丝线环绕肺动脉主干2周后收紧，暂不打结，将线的两端用蚊式钳固定于操作孔周围的无菌中单，然后将哈巴狗钳置于0号线远端约5mm处，远端血管使用0号线阻断。结果10例左全肺切除联合纵隔淋巴结清扫术，5例右全肺切除联合纵隔淋巴结清扫术。肺动脉成形时间平均14min（10～19min），平均手术时间180．6min（120～231min），平均出血量100ml（50～250ml）。术中、术后未输血，无围手术期并发症发生。术后病理：10例鳞癌，2例腺癌，2例小细胞肺癌，1例大细胞肺癌；病理分期：ⅢA期12例，ⅡB期2例，ⅡA期1例。平均住院时间7d（6～9d）。14例术后随访1年，1例术后5个月死于对侧肺部感染，1例术后10个月死于脑转移，余12例无复发。结论改良肺动脉成形方法可行。

A Modified Video-assisted Thoracoscopic Surgery for Pulmonary Artery Reconstruction in Pneumonectomy

Objective To evaluate the feasibility of a modified technique of pulmonary artery （PA） reconstruction during video-assisted thoracic surgery （VATS） for patients with lung cancer invading hilum pulmonis. Methods Between April 2012 and October 2012, pneumoectomy combined with pulmonary arterioplasty was performed on 15 patients with lung cancer invading hilum pulmonis. The new modified steps of PA reconstruction in our study were as follows： after blocking and dissecting of the superior pulmonary vein and inferior pulmonary vein, proximal control of the pulmonary artery stem was visualized. Instead of using the control technique of Ryoichi Nakanishi and Toshihiro Yamashita, we applied No. 0 silk braided non-absorbable suture （Ethicon, Somerville, N J） and bulldog clamp to perform PA control. The first step was that the proximal PA was encircled by the non-absorbable suture, and then the suture was tightened up without knotting and was lifted and fixed by a mosquito forcep. Then two ends of No. 0 silk braided non-absorbable suture were drawn by a long Kelly clamp, and one bulldog clamp was placed next to the suture. PA trnncus was subsequently ligated by No. 0 silk braided non-absorbable suture. Results We performed pneumocctomy combined with pulmonary arterioplasty including a systemic mediastinal lymphadenectomy on 15 patients （ including 10 cases of left penumoectomy and 5 cases of right penumoectomy）. The mean PA repairing time was 14 min（ range, 10 -19 min）; the operation time was 180.6 min（ range, 120 -231 min） and the blood loss was 100 ml （range, 50 -250ml）. No patients required blood transfusion during the intraoperative or postoperative period. No perioperative complications were observed. Postoperative pathologic examination showed 10 cases of squamous carcinoma, 2 cases of adenocarcinoma, 2 cases of small cell lung cancer and 1 case of large cell carcinoma; pathological stage included 12 cases of III A ,2 cases of II B and 1 case of II A. The mean postoperative hospital stay was 7 d（range, 6 -9 d）. Fourteen cases were followed up for 1 year postoperatively. One patient died of pulmonary infection 5 months after operation; 1 patient died of brain metastases 11 months after operation; no evidence of recurrence was observed in other patients. Conclusion The modified PA reconstruction is feasible.