后腹腔镜下腹膜后淋巴结清扫术七例报告

目的 探讨后腹腔镜下腹膜后淋巴结清扫术(LRPLND)的方法. 方法 采用后腹腔镜技术行腹膜后淋巴结清扫术7例.患者均为男性,年龄27～39岁,平均31岁.其中睾丸混合癌2例(精原合并胚胎癌为主)、内胚窦瘤2例、绒毛膜上皮癌1例、精原合并畸胎瘤2例;右侧2例,左侧5例.临床分期均为Ⅰ期.全麻,健侧卧位,双气囊扩张法建立后腹腔间隙,分离肾前筋膜与腹膜间及肾后筋膜与腰肌的平面间隙直至髂窝;精索静脉高位结扎切断,自肾门平面向下清除肾前及.肾后筋膜内的脂肪淋巴组织和精索血管;沿腔静脉(右)或腹主动脉(左)的肾门平面起在其后方剪开血管鞘膜,清扫表面的脂肪淋巴组织;注意保护肠系膜下动脉及其对侧的脂肪淋巴组织,在精索跨越髂血管后尽量低位分离.结果最初2例术中穿透腹膜,中转开放手术.后5例腹腔镜下手术成功,平均手术时间285(245350)min,失血100～250 ml.后5例患者中,术后病理分期与临床分期一致4例,1例术后检出2枚阳性淋巴结;每例清扫淋巴结22～31枚,平均25.6枚.随访3～20个月,CT检查未见复发及远处转移,肿瘤标记物检测正常范围.术后1个月内均恢复性功能. 结论 经后腹腔途径的LRPLND可从侧方整体游离清除脂肪淋巴组织,清扫顺序自上而下,手术空间大,解剖标志清晰,可达到与开放手术相同的切除范围,符合肿瘤治疗原则,可用于临床Ⅰ期非精原细胞瘤的诊断及治疗.

Extroperitoneal laparoscopic retroperitoneal lymph node dissection(report of 7 cases)

Objective To investigate the techniques of laparoscopic retroperitoneal lymph node dissection(LRPLND)through extraperitoneal approach. Methods Seven non-seminomatous germ cell testicular tumor(NSGCT)patients of clinical stage Ⅰ underwent LRPLND through extraperitoneal approach.The average age was 31(27-39 years old),the average weight was 62 kg(weight 58-72 kg).Pathological examination revealed 2 testis mixed carcinoma(major of embryonal carclnoma and seminoma),2 yolk sac tumor,1 ehoriocarcinoma,2 teratoma with seminoma.Two of them were in right side,and 5 in left.All the chest X-ray,abdominal CT and bone scanning of them were normal before operation.All patients were general anesthetized.Three or 4 trocars were placed,from 2 of them two gasbags were used to expand the retroperitoneal space at volume of 800-900 ml.The retroperitoneal fat was cleared off from the surface of Gerota's fascia to iliac fossa and the plane spance betwwwn anterior rena fascia and posterior peritoneum was separated In the same way the Plane between dorsal renal and the surface of psoas major and quadratus lumborum unto iliae lossa was exposed.Abdominal aorta or vena cava was exposed,then divided and dissected free from surfaee of psoas maior.The conflux of renal vein and testicular vein at the deep face of renal artere(left)was exposed,then testicular vein was ligated and divided it at its end.Fat and lymph tissue between ureter and vessels was dissected to the crotch of abdominal aorta or inferior vena cava.The primary inguinal incision of testectomy was then excided.Normal antegrade ejaculation recovered in 1 month postoperatively. Results The initial 2 operations were converted to open way as the peritoneum were penetrated largely.The other 5 operations were successful.The average operating time was 285 min(245-350 min),intraoperative blood loss was 100-250 ml.Four patients'pathologic results accorded with clinical staging,and 2 positive lymph nodes were found in the other one.The average number of lymph node resected was 25.6 counts(22-31).Follow-up for 3-20 months,chest X-ray and abdominal CT revealed no evidence of recurrence or distant metastasis,and serum tumor markers were in normal range.Normal antegrade ejaculation recovered in 1 month postoperatively. Conclusions The technique through extraperitoneal approach could be applied for LRPLND.It might be an approach for diagnosis and treatment of stage Ⅰ NSGCT.