腹腔镜全直肠系膜切除外科入路的解剖观察

目的 探讨腹腔镜直肠癌根治的可行性和安全性.方法 对符合腹腔镜全直肠系膜切除(total mesorectal excision,TME)适应证的28例直肠癌患者进行TME手术肿瘤学结果评价;观察腹腔镜下直肠癌全直肠系膜切除解剖学特点及外科入路.结果 手术平均时间173 min(120-245 min);术中平均失血量67 ml(20-200 ml);术后3-7 d(平均5 d)拔除导尿管;术后48-120 h排气,平均72 h;术后3 d腹腔平均引流量133 ml(20-475 ml).肠管标本切除长度16.2 cm(10-26 cm);肿瘤近端切缘间距平均13.0 cm(10.5-16.5 cm);肿瘤远端切缘间距平均3.5 cm(2-6 cm);淋巴结清扫数目12-20枚,平均16枚;阳性淋巴结平均数目1枚(0-6枚).腹腔镜下以Toldt's交界线、乙状结肠粘连带及骶岬、腹膜折返等固有解剖标志可逐步游离进入左侧Toldt's间隙、骶前间隙、Denonvillier's筋膜间隙及直肠侧间隙,实现直肠癌的规范化TME.结论 腹腔镜直肠癌TME具有可行性及安全性,遵循"无瘤触碰、肿块切除、系膜完整切除、合理清扫淋巴范围"基本原则下,肿瘤学结果可达到2010NCCN直肠癌根治标准.腹腔镜具有术野放大效应,利于直视下锐性游离依次进入左侧Toldt's间隙、骶前间隙、Denonvillier's筋膜间隙及直肠侧间隙所组成的直肠外科平面实施规范化TME.

The surgical approach:laparascopic total mesorectal excision for rectal cancer

Objective To explore the feasibility and security of laparascopic total mesorectal excision for rectal cancer.Methods A total of 28 patients with colorectal cancer consecutively undergoing the laparascopic total mesorectal excision were enrolled.The related indicators of surgical oncology and postoperative recovery were observed.Laparascopic surgical approach and anatomical plane were observed.Results The average operation time was 173 min(120-245 min),blood loss volume averaged 67 ml(20-200 ml),catheter time was 5 d(3-7 d),exhausted time was 72 h(48-120 h),abdominal drainage within 3 d was 133 ml(20-475 ml).Specimen length was 16.2 cm(10-26 cm),proximal tumor margin was 13.0 cm(10.5-16.5 cm),distal margin-tumor was 3.5 cm(2-65 cm),number of harvested lymph node was 16(12-20);number of positive lymph nodes was 1(0-6).Under the guidance of anatomic landmarks,such as Toldt’s boundary line,sigmoid colon adhesion,sacral promontory,and peritoneal reentry,the standard laparascopic TME was achieved through left Toldt’s free space,presacral space,Denonvillier’s fascia space and rectal bilateral spaces.Conclusion Following the laparotomic principles of "no-touching tumor,tumor removal,complete mesorectal excision and rational lymphadenectomy",laparascopic TME is feasible and safe,and the oncological results could achieve to 2010NCCN rectal surgical standards.It is conducive to free the rectal surgical plane sharply with the good laparascopic amplified effects.