胃网膜血管弓内入路在腹腔镜下胃上部癌脾门淋巴结清扫术中的应用

目的探讨胃网膜血管弓内入路优先离断脾胃韧带的腹腔镜保脾的脾门淋巴结清扫技术在胃上部癌的有效性及安全性应用。方法选取2018年10月至2019年2月于烟台毓璜顶医院胃肠外一科因胃上部癌行腹腔镜下全胃切除的患者20例,采用胃网膜血管弓内入路先离断脾胃韧带的技术进行清扫脾门淋巴结。记录总手术时间,术中出血量;清扫脾门淋巴结的手术时间及出血量;总清扫淋巴结数目及转移性淋巴结数目;脾门淋巴结清扫总数及转移淋巴结数目;术后排气时间、进食流质时间及术后住院时间;术后并发症如腹腔感染、吻合口瘘、肺部感染、切口感染、出血及是否中转开腹、脾缺血及脾坏死等脾门淋巴结清扫相关并发症。术后1年采用电话随访、门诊随访等方法进行随访。结果所有患者均成功实施腹腔镜全胃切除加脾门淋巴结清扫。总手术时间(240.8±31.7)min,范围200~268min;术中出血量(90.4±43.8)ml,范围50~200 ml;脾门淋巴结清扫时间(18.5±4.0)min;脾门淋巴结清扫出血量(10.2±5.8)ml,范围5~20 ml;清扫总淋巴结数目(37.68±3.89)枚,范围25~58枚,转移性淋巴结数目(4.31±2.54)枚;脾门淋巴结(3.51±1.79)枚,范围2~10枚;转移性脾门淋巴结(0.98±1.19)枚,范围0~4枚。术后肛门排气时间(3.5±1.9)d,术后进食流质时间(4.5±1.7)d,术后住院时间为(7.5±1.5)d。术后并发症:腹腔感染1例,肺部感染1例,吻合口瘘1例;无中转开腹、脾缺血及脾坏死等脾门淋巴结清扫相关并发症。术后1年未有患者因肿瘤复发或转移,无死亡病例。结论胃网膜血管弓内入路优先离断脾胃韧带的腹腔镜保脾的原位脾门淋巴结清扫术安全有效。

The application of laparoscopic splenic hilar lymphadenectomy in the treatment of upper gastric cancer

Objective To evaluate the efficacy and safety of laparoscopic spleen-preserving splenic hilar lymphadenectomy through endovascular arch approach for superior gastric cancer.Methods From Oct.2018 to Feb.2019,20 cases of upper gastric cancer underwent laparoscopic total gastrectomy in Gastrointestinal Surgery Ward 1 of Yantai Yuhuangding Hospital.The splenic hilar lymph nodes were dissected by endogastric omentum vascular arch approach.The total operation time,intraoperative bleeding volume,operation time and bleeding volume of splenic hilar lymph nodes dissection,total number of lymph nodes and metastatic lymph nodes,number of splenic hilar lymph nodes and metastatic lymph nodes,postoperative exhaust time,first feeding fluid time and postoperative hospital stay time,and postoperative complications such as abdominal infection,anastomotic leakage,pulmonary infection,incision infection and bleeding were recorded.The complications of splenic hilar lymph node dissection were bleeding,conversion to laparotomy,splenic ischemia and splenic necrosis.One year after operation,follow-up was carried out by telephone and outpatient.Results Laparoscopic total gastrectomy and splenic hilar lymph node dissection were successfully performed in all cases.The total operation time ranged from 200 to 268 min,with an average of(240.8±31.7)min,intraoperative bleeding volume of 50 to 200 ml,with an average of(90.4±43.8)ml;the time of splenic lymph node dissection was(18.5±4.0)min;the amount of splenic lymph node dissection bleeding ranged from 5 to 20 ml,with an average of(10.2±5.8)ml;the number of total lymph nodes dissection was 25 to 58,with an average of 37.68±3.89 and the number of metastatic lymph nodes 4.31±2.54;The number of splenic lymph nodes was 2 to 10,with an average of 3.51±1.79;The number of metastatic lymph nodes was 0 to 4 lymph nodes,with an average of 0.98±1.19.The average time of anal exhaust was(3.5±1.9)days,the time of fluid intake was(4.5±1.7)days,and the postoperative hospital stay was(7.5±1.5)days.Postoperative complications were as following:one case had abdominal infection,one had pulmonary infection,one had anastomotic leakage and there were no complications related to splenic hilar lymph node dissection such as conversion to laparotomy,splenic ischemia or splenic necrosis.There was no recurrence or metastasis of the tumor and no death occurred one year after the operation.Conclusion Laparoscopic spleen-preserving splenic hilar lymphadenectomy via endovascular arch approach is safe and effective.