109枚直径小于20mm的肺内结节的胸腔镜诊疗  

Clinical experience of VATS diagnosis and treatment of pulmonary nodules less than 20 mm in size

作　　者：刘道明[1] 周顺楷[1] 花梅免[1] 冯学刚[1] 连铎煌[1] 陈朝阳[1] 陈龙[1] 杨胜生[1] 

机构地区：[1]南京军区福州总医院胸心外科,福州350025

出　　处：《中华胸心血管外科杂志》2012年第7期394-397,共4页Chinese Journal of Thoracic and Cardiovascular Surgery

摘　　要：目的探讨胸腔镜下手指触摸法定位肺内小结节的应用价值和技术细节，以及cT对肺小结节诊疗的指导作用。方法95例患者CT检查出直径小于20mm的肺内结节109枚，直径（d）平均10mm，结节距脏层胸膜最短距离（D）平均8．2mm。定位难度参考D／d值。术前建立每个结节的影像特征信息。胸腔镜下经腋前线第4或第5肋间，以食指进行触摸定位。依结节的不同深度，选择楔形或肺叶切除并行活检，根据术中病理决定最终术式。测算深部结节至段支气管起始部的距离（L），考察该指标预测活检术式的参考价值。结果109枚结节均在腔镜下触摸并成功定位，105枚行楔形切除活检；4枚距段支气管起始部18～30mm，平均26．1cm，行肺叶切除活检。根据冰冻病理，55例肺癌患者最终行肺癌根治术。结论胸腔镜下手指触摸法可以有效定位任何位置的肺内小结节。利用数字化的CT信息建立参照体系、术中充分游离纵隔胸膜是提高触摸法定位成功率的关键。深部结节距离段支气管起始部〈30mm时应考虑行肺叶或肺段切除活检。Objective To evaluate the technique of finger palpation in thoracoscopic localization in patients with pulmo- nary nodules, and to summarize its technical details, especially with exploit of chest computed tomography （CT） facilitating it. Methods 95 patients with total amount of 109 pulmonary nodes 20 mm or smaller in size shown with lung window of CT, were reviewed. They were located subpleurally, with a median depth of 8.2 mm and a median size of 10. 0 mm. The value of their depth over their size （ D/d value） could be used as the extent of localizing difficulty. Each node had its own radiographic fea- tures for being localized, which was built preoperatively. Under thoracoscopic vision, nodules were finger-palpated by index finger via the 4th or 5th intercostal space on anterior axillary line, followed by wedgectomy or lobectomy for instant histopatho- logical diagnosis to further decide the final surgical type. The distance between the nodule and the origin of segmental bronchus （ L value） were also calculated out, as it might be relevant to the way the nodule could be biopsied. Results All nodules were successfully localized and resected for biopsy goal, 105 by wedgectomy, 4 by lobectomy. After intraoperative diagnosis was made by the pathologist, VATS lobectomy and lymph node dissection were further performed in 55 patients. L value of 4 cases being biopsied by lobectomy ranged from 18. 3 to 30.3 mm, averaging 26. 1 mm. Conclusion Finger palpation is viable in any cases of pulmonary nodules. Detailed reference of CT digital information, and enough detachment of mediastinal pleura, can greatly facilitate thoracoscopic localization by finger palpation. Lobectomy or segementectomy is preferable when L value is less than 30 mm.

关 键 词：电视胸腔镜手术 孤立性肺结节 肺楔形切除术 肺叶切除术 

分 类 号：R655.3[医药卫生—外科学]