腹腔鏡輔助結(jié)直腸癌切除術(shù)１４例報(bào)告.doc

腹腔鏡輔助結(jié)直腸癌切除術(shù)例報(bào)告【摘要】 目的：探討腹腔鏡技術(shù)在結(jié)直腸癌切除術(shù)中的應(yīng)用。方法：回顧分析腹腔鏡輔助結(jié)直腸癌切除術(shù)例的臨床資料。結(jié)果：本組右半結(jié)腸、橫結(jié)腸、左半結(jié)腸以及乙狀結(jié)腸根治性切除各例，ixon術(shù)例，Miles術(shù)例；例左半結(jié)腸癌患者探查見左腎有浸潤(rùn)性轉(zhuǎn)移而中轉(zhuǎn)開腹；例橫結(jié)腸癌患者探查見腫瘤腹腔廣泛轉(zhuǎn)移而放棄手術(shù)；全組無手術(shù)死亡。術(shù)后例Dukes D期患者因腫瘤轉(zhuǎn)移死亡，例Dukes 期患者年后腸道復(fù)發(fā)，其余患者未見腫瘤復(fù)發(fā)及轉(zhuǎn)移。結(jié)論：腹腔鏡輔助結(jié)直腸癌根治術(shù)安全可行。 【關(guān)鍵詞】 結(jié)直腸腫瘤；腹腔鏡Laparoscopicallyassisted resection for 14 cases with colorectal cancers 【Abstract】 bjective:o explore the clinical application of the laparoscopicallyassisted resection for colorectal cancers.Methods:The clinical data of 14 cases with colorectal cancer underwent laparoscopicallyassisted operation were analyzed retrospectively.Results:All patients received laparoscopic operation.Right hemicolectomy was performed in 1 case,transverse colectomy was performed in 1 case,lefthemicolectomy was performed in 1 case,sigmoidectomy was performed in 1 case.Dixon operation was performed in 5 cases and Miles operation was performed in 3 cases.There was no death due to operation.1 case with transverse colon cancer found extensive transplantation in abdominal cavity was converted to open operation.1 case with lefthemicolon cancer was convevted to laparotomy because of the invision of the left kidney.1 case with Dukes C stage perioperative recurred one year later and 1 case with Dukes D stage died during perioperative time because of transplantation.Conclusions:Laparoscopicallyassisted resection for colorectal cancers is a feasible and safe procedure.【Key words】 Colorectal neoplasms;Laparoscopy自年月美國(guó)的acobs施行了世界上首例腹腔鏡右半結(jié)腸切除術(shù)以來，經(jīng)過余年的發(fā)展，腹腔鏡手術(shù)已發(fā)展到結(jié)直腸外科的各種術(shù)式。年月至年月我院共施行腹腔鏡輔助結(jié)直腸癌切除術(shù)例，現(xiàn)報(bào)道如下。1 資料與方法11 臨床資料 例患者中男例，女例；歲，平均歲。其中橫結(jié)腸癌例，降結(jié)腸癌例，乙狀結(jié)腸癌例，直腸癌例。ukes A期例、期例、期例、期例。 手術(shù)方法 全麻下直腸及乙狀結(jié)腸癌患者取頭低足高截石位，降結(jié)腸癌患者取頭低足高右傾位，橫結(jié)腸癌患者取頭高足低截石位。建立氣腹，氣腹壓為mm Hg。分別于臍上置觀察孔，于左右麥?zhǔn)宵c(diǎn)及相應(yīng)位置置個(gè)操作孔，置入腹腔鏡、超聲刀及操作鉗。常規(guī)探查腹腔內(nèi)臟器，明確腫瘤所在位置及有無轉(zhuǎn)移。在腫瘤近端置紗帶扎緊腸管及其系膜，用超聲刀切開后腹膜及腸系膜，分離腸系膜血管至根部離斷。橫結(jié)腸癌及降結(jié)腸癌患者在腹部相應(yīng)部位作cm長(zhǎng)切口，提出游離腸段，在腹腔外距腫瘤cm以上處切除腸段，行兩斷端腸管吻合后，還納回腹腔。乙狀結(jié)腸癌和直腸癌患者于腫瘤上緣cm處用超聲刀分離乙狀結(jié)腸系膜至腸系膜下血管處離斷，并行盆腔銳性清掃，保護(hù)輸尿管，進(jìn)入直腸后間隙，于骶前筋膜前方在腹腔鏡直視下銳性分離，達(dá)腫瘤下緣cm處。如腫瘤下緣距肛門緣cm，則循盆筋膜壁層和臟層界面行銳性解剖，小骨盆內(nèi)銳性清掃腫瘤遠(yuǎn)端cm的全部直腸系膜組織，在提肛肌上保留cm腸段，用吻合器行結(jié)直腸吻合術(shù)。如腫瘤下緣距肛門緣小于cm，則行腹會(huì)陰切除術(shù)，乙狀結(jié)腸造瘺。所有病變腸段在拖出腹腔前均用無菌塑料袋保護(hù)切口。2 結(jié)果 例中行右半結(jié)腸、橫結(jié)腸、左半結(jié)腸以及乙狀結(jié)腸根治性切除各例，Dixon術(shù)例，Miles術(shù)例；例左半結(jié)腸癌患者腹腔鏡探查見左腎有浸潤(rùn)性轉(zhuǎn)移而中轉(zhuǎn)開腹；例橫結(jié)腸癌患者經(jīng)腹腔鏡探查見腫瘤腹腔內(nèi)廣泛轉(zhuǎn)移而放棄手術(shù)。手術(shù)時(shí)間min，平均min，全組無手術(shù)死亡病例。全組患者于術(shù)后h內(nèi)均恢復(fù)腸道功能。術(shù)后病理示高分化腺癌例、高中分化腺癌例、中低分化腺癌例、粘液腺癌例。隨訪個(gè)月至年，隨訪形式以術(shù)后化療、門診復(fù)查及電話咨詢?yōu)橹?。例橫結(jié)腸癌腹腔廣泛轉(zhuǎn)移者月后死亡，例Dukes 期患者年后腸道復(fù)發(fā)。所有患者其穿刺孔及輔助小切口均未見腫瘤種植轉(zhuǎn)移。 討論 腫瘤根治的徹底性以及腹腔鏡手術(shù)能否引起腫瘤擴(kuò)散與轉(zhuǎn)移是腹腔鏡結(jié)直腸癌切除的關(guān)鍵問題。為此, 國(guó)內(nèi)外的外科專家進(jìn)行了大量的研究總結(jié)。Moore等研究了腹腔鏡輔助下結(jié)直腸癌切除術(shù)的病理標(biāo)本,其腫瘤切除范圍及淋巴清掃均與開腹手術(shù)無明顯差異。Franklin等報(bào)道了191例腹腔鏡和224例開放式結(jié)直腸癌手術(shù)的隨機(jī)對(duì)照研究,兩者在切除腸段長(zhǎng)度、腫瘤上下切端長(zhǎng)度以及淋巴結(jié)清除數(shù)量上均無統(tǒng)計(jì)學(xué)差異。大量的研究和臨床實(shí)踐均證實(shí)腹腔鏡結(jié)直腸手術(shù)在腫瘤根治上達(dá)到了與開腹手術(shù)相同的療效,是安全可靠的,技術(shù)上是可行的。切口的腫瘤種植是人們普遍擔(dān)心的另一個(gè)問題。近年一些學(xué)者研究表明4,腹腔鏡手術(shù)后引起腫瘤切口種植的機(jī)制主要有（）脫落腫瘤細(xì)胞的直接種植；(2)手術(shù)過程中器材粘附腫瘤細(xì)胞造成切口污染；(3）腫瘤細(xì)胞的氣霧化作用；（）不同膨腹氣體對(duì)體內(nèi)環(huán)境的影響；（）人工氣腹對(duì)細(xì)胞免疫的影響；(6）血行播散。但通過保護(hù)切口及采取一些相應(yīng)的預(yù)防措施,可以降低術(shù)后的切口腫瘤種植率。我們的體會(huì)是用無菌塑料袋保護(hù)切口,既可有效地防止切口的腫瘤種植,又便于將病變腸段拖出腹腔。結(jié)腸的淋巴引流與原發(fā)病灶呈扇形分布,行腹腔鏡手術(shù)較易徹底切除。肝、脾曲以及橫結(jié)腸腫瘤,因需清除結(jié)腸中動(dòng)脈的淋巴結(jié)以及大網(wǎng)膜豐富的血供,腹腔鏡下操作較為困難。而采用腹腔鏡輔助手術(shù)，可將游離的腸段提出腹腔,直視下清掃，結(jié)合了兩者的優(yōu)點(diǎn)，彌補(bǔ)了兩者的不足。直腸腫瘤的上段相對(duì)較易切除；下1/3 段則常需行Miles術(shù),腹腔鏡完全可以達(dá)到與開腹手術(shù)相同的切除范圍;直腸中下 1/3 段腫瘤行直腸全系膜切除術(shù)已被眾多學(xué)者認(rèn)可。與開腹手術(shù)相比，在腹腔鏡下分離直腸系膜,對(duì)盆筋膜臟壁兩層間疏松結(jié)締組織間隙的判斷和入路選擇更為準(zhǔn)確,并可抵達(dá)狹窄的小骨盆,在直視下切斷直腸側(cè)韌帶,對(duì)盆腔植物神經(jīng)叢的識(shí)別和保護(hù)更確切,應(yīng)用超聲刀銳性解剖能夠更完整地切除直腸系膜?？傊?只要嚴(yán)格掌握腹腔鏡腫瘤手術(shù)的適應(yīng)證,遵循無瘤手術(shù)原則,腹腔鏡輔助結(jié)直腸腫瘤手術(shù)是安全可行的。參考文獻(xiàn)： Jacobs M,Verdeja JC,Goldstein HS.Minimally invasive colon resection(Laparoscopic colectomy).Surg Laparosc Endosc,1991,1:144-150. Moore JW,Bokey EL,Newland RC,et al.Lymphovascular clearance in laparoscopically assisted right hemicolectomy is similar to open surgery.Aust N Z J Sur