经腹腹腔镜下右肾周筋膜解剖研究及其在腹腔镜右肾切除中应用价值

目的通过研究经腹途径腹腔镜下右肾肾周筋膜的分层结构,为腹腔镜筋膜入路右肾切除手术的可行性及安全性提供解剖学依据。方法在国内外学者对肾周筋膜研究的基础上结合CT肾周筋膜的呈现,对经腹途径腹腔镜下肾周筋膜分层结构进行研究,并以此为基础设计好手术的筋膜入路及分离途径并应用于指导经腹腹腔镜下右肾切除术,记录2015年1月至2019年6月来自阳江市中医医院和人民医院的45例患者的术中肾周筋膜观察结果及手术时间、出血及术中术后并发症等。结果经腹途径腹腔镜下肾周间隙周围存在一个潜在连续的由疏松纤维条索填充的无血管层面,这个无血管层面存在于相邻的两层肾周筋膜之间,45例患者均按术前设计的手术路径顺利完成手术,其中42例患者可以很好或较好的保持筋膜完整性的情况下完成分离,2例脓肾患者及1例无功能肾患者由于粘连明显未能保持分离面筋膜完整性,平均手术时间73 min,平均出血50 ml,术后引流管时间2.7 d,术中无肠管及下腔静脉损伤病例,术后无肠漏及严重的继发出血病例,无围手术期死亡病例。结论肾周筋膜的分层结构及肾周间隙周围存在的连续的潜在无血管层面为经腹途径腹腔镜筋膜入路右肾切除有效的解剖依据,经腹腹腔镜下筋膜入路右肾切除是安全可行的,可以让手术更加安全及出血更少。

The study of perirenal fascial anatomy of right kidney in transperitoneal laparoscopic nephrectomy

ObjectiveTo explore the value of perirenal fascia of the right kidney in transperitoneal laparoscopic nephrectomy. MethodsThe feature of perirenal fascia was studied in order to design the fascial approach and the method of departure for the transperitoneal laparoscopic nephrectomy, base on the study of perirenal fascia and CT of the morphologic features of perirenal fascia. The perirenal fascia intraoperation,operation time, blood loss and the complications were observed in the 45 patients in our hospital from January 2015 to June 2019. ResultsThere was a bloodless layer fulled with fibrous bands surrounded the perirenal space, this bloodless layer was located between the adjacent perirenal fascias. All surgeries of 45 cases were performed successfully as the method that designed preoperatively, 42 cases kept the integrity of the fascia, but 2 cases with pyonephrosis and 1 case with non-functioning kiney could not be kept the integrity of the fascia. average operation time was 73 mins, average blood loss 50 ml, average drainage time 2.7 days, no inferior vena cava and bowel injries occurred. No perioperative death occurred. ConclusionThe layered structure of the perirenal fascia and the bloodless layer surrounded the perirenal space provide a helpful anatomic evidence of transperitoneal laparoscopic nephrectomy. The fascial approach of transperitoneal laparoscopic nephrectomy is safe and feasible.