经腹膜后途径二次肾区腹腔镜手术的探讨

目的探讨二次肾区经腹膜后腹腔镜手术治疗泌尿系疾病的可行性。方法 2006年1月～2012年1月我院对7例有同侧开放或腹腔镜经腹膜后途径手术史者经腹膜后途径行二次肾区腹腔镜手术,其中2例为肾上腺嗜铬细胞瘤术后复发,2例为肾囊肿术后同侧复发,1例为开放肾盂输尿管连接部成形术后继发肾积水导致无功能肾,1例为后腹腔镜肾上腺肿物切除术后同侧肾萎缩无功能,1例为肾癌肾部分切除术后复发。2次手术间隔2.5～8.3年,平均3.5年。第2次手术均取经腹膜后入路,直视下经第12肋下2 cm与骶棘肌外侧交界处进入后腹腔建立气腹,在腋中线髂嵴上2 cm处做第2穿刺点,腋前线肋缘下为第3穿刺点,先从解剖清晰、粘连轻处按解剖层次,逐步暴露手术部位完成手术。结果手术均获成功,手术时间75～213 min,平均131 min;术中出血量50～400 ml,平均156 ml。2例腹膜损伤,无腹腔内脏器损伤,术后第3天胃肠道恢复,逐渐进食。术后住院4～12 d,平均9 d。6例随访4～38个月,平均18个月,患者恢复良好,肾囊肿及肿瘤未见复发。结论在熟练掌握后腹腔镜技术的前提下,再次后腹腔镜下肾区手术是可行的。

Retroperitoneal Laparoscopic Re-operation in the Nephron Region

Objective To investigate the feasibility of re-operation in the nephron region by retroperitoneal laparoscopy for urinary diseases. Methods Seven patients who underwent retroperitoneal laparoscopy for a second operation from January 2006 to January 2012 in our hospital, were analyzed retrospectively. All the patients had received an ipsilateral operation by open or retroperitoneal laparoscopic approaches. Among the patients, two were diagnosed with recurrent pheochromocytoma, two had ipsilateral recurrent renal cyst, one had a nonfunctioning left kidney because of secondary hydronephrosis after an open ureteropelvic junction plasty, one had left kidney atrophy after retroperitoneal laparoscopic resection of adrenal tumor, and one showed recurrent renal cancer after a subtotal resection. The interval between the two operations ranged from 2. 5 to 8. 3 years with a mean of 3. 5 years. Retroperitoneal laparoscopic approach was employed in all the patients for the second operation. Through an incision at the lateral border of the sacrospinal muscle, 2 cm below the 12th rib, we introduced the first trocar into the abdominal cavity and established pneumoperitoneum, and then a second and third puncture sites were made at the midaxillary line 2 cm above the crista iliaca and anterior axillary line below the costal margin respectively. The lesions were removed finally by separating the tissues layer by layer. Results The procedure was completed in all the patients within 75 -213 min （mean, 131 min）. The intraoperative blood loss was 156 ml in average （ranged from 50 to 400 ml）. The patients were discharged from hospital in 4 to 12 days （mean, 9 days） after the second surgery, and then 6 of them received a follow-up for 4 to 38 months （mean, 18 months）. All the patients recovered well without recurrent tumor or cyst. Conclusion Re-operation in the nephron region by retroperitoneal laparoscopy is feasible in properly selected cases with skilled and experienced hands.