3讨论国内外大量研究表明,腹腔镜结直肠癌根治术是一种很好的方法,它在肿瘤切除的范围,清扫淋巴结的数量等方面与传统手术无显着差异[2]。且并未增加术后肿瘤的复发率[3]。但如何选择合适的病例、手术技术的提高以及并发症的防治仍有值得探讨的地方。
2结果全组70例中,69例手术成功,1例上段直肠癌侵及膀胱后壁中转开腹。手术时间110~210min,平均140min。术中失血30~300ml,平均100ml。无手术死亡,无输尿管损伤、术后出血、吻合口瘘等并发症。4例术后早期尿潴留,5例术后
性功能障碍,除9例Miles术式外,其余患者均未用镇痛剂。术后下地时间1~4d,平均3d,肠蠕动恢复1~3d,平均16d。术后住院时间5~8d,平均7d。所有病例未见切缘癌细胞残留。全组病例随访1~39月,平均12月。1例腹壁穿刺孔种植转移,2例广泛转移,其中1例巨大直肠上段癌(10cm×6cm×5cm),已侵犯浆膜层,术后3个月出现腹腔盆腔内广泛转移并引起梗阻,再次手术探查解除梗阻,另1例术后12个月腹腔、肝脏广泛转移。另1例术后2个月发生肝脏多灶转移,再行介入治疗。
12手术方法均采用全麻,取头低足高截石位。气腹压力设定为15mm Hg,脐部10mm作观察孔,置入腹腔镜,其余操作孔视病灶位置而定。手术操作过程基本同文献报道[1],但应注意以下几个方面:(1)直肠前切除术(Dixon术):充分暴露盆腔以及Douglas窝,女性患者先以直针悬吊子宫,大致了解肿瘤的位置、大小。解剖肠系膜下动、静脉,清扫根部淋巴结后离断。于根部以超声刀离断乙状结肠、直肠上段系膜,游离相应肠段,游离直肠下段时应以超声刀锐性分离盆腔筋膜脏壁两层之间的疏松间隙,彻底切除直肠侧韧带。肿瘤定位不清时应以手指或纤维肠镜术中定位,以保证根治的彻底性,取出病变肠段时应保护切口。本组52例行此术式。(2)腹会阴联合直肠切除术(Miles术):女性患者分离直肠阴道间隙时常需助手将手指伸入阴道引导。为保证上、下手术组分离间隙的一致,会阴手术组应在腹腔镜操作钳引导下逐层深入,必要时常从某一位置率先突破入盆腔,以便于其它部位的分离。本组9例行此术式;(3)右半结肠切除术:解剖出右侧输尿管,加以保护,分离右结肠动脉(本组2例中有1例缺如),于根部置钛夹后离断。游离回肠末段约15~20cm和升结肠,清扫结肠中动脉根部之淋巴结,离断中动脉右支,以无菌套保护切口后将游离肠段拉出体外切除、对端吻合,缝闭系膜孔后回纳腹腔。本组2例行此术式;(4)乙状结肠切除术:手术操作基本同直肠前切除术,4例切除后在体外行手工吻合,3例以双吻合器吻合。
1资料与方法11临床资料70例中男45例,女25例。25~85岁,平均53岁。中上段直肠癌10例(距肛缘7cm以上),低位直肠癌51例,回盲部肿瘤2例,乙状
结肠癌7例。肿瘤直径15~10cm,平均46cm。Dukes分期A期15例,B期18例,C期35例(C1期23例,C2期12例),D期2例。病理类型:高分化腺癌17例,中分化腺癌28例,低分化腺癌20例,管状腺瘤伴不典型增生5例。
【Key words】Laparoscopy;Colorectal tumor我院2001年9月~2004年12月开展腹腔镜结直肠手术70例,疗效满意,报道如下。
【关键词】腹腔镜;结直肠肿瘤Clinical analysis of laparoscopic surgery for coloreced【Abstract】Objective:To study the clinical value of laparoscopic surgery for coloreced neoplasm.Methods:70 cases of colorectal neoplasms underwent laparoscopic surgery based on the traditional operation principle.Were analyzed 2 cases underwent right hemicolectomy.7 cases underwent sigmoidectomy.52 cases were performed rectal anterior resection for rectal cancer(Dixon).Abdominal perineal resection was conducted in 9 cases.Results:69 cases succeeded,l case was converted to open laparotomy because of invading bladder.The mean time of operation was 1 40min,and average intraoperative bleeding was 120ml.The average time of the recovery of intestinal function was 1.6 days.5 cases arised sex dysfunction and 4 cases were urinary retention early stage of postoperation.No another postoperative complicotion such as bleeding,leakage occurred.All patients were followed up 139 months.2 cases widespread metastasize in abdominal cavity and another 2 cases metastasize in live 1case was found trocar site implantation.Conclusions:The laparoscopic operation to colorectal neoplasms is both feasible and safe.It must be performed under the good indication by skilled and experienced surgeon.