经阴道自然腔道内镜手术辅助腹腔镜下肾部分切除术的临床研究  

Transvaginal natural orifice transluminal endoscopic surgery （NOTES）-assisted laparoscopic partial nephrectomy

作　　者：王晓宁[1] 张国玺[1] 邹晓峰[1] 袁源湖[1] 肖日海[1] 伍耿青[1] 薛义军[1] 刘佛林[1] 徐辉[1] 江波[1] 徐瑞权[1] 刘全亮[1] 曾晓鹏[1] 曾庆明[1] 

机构地区：[1]赣南医学院第一附属医院泌尿外科赣南医学院泌尿外科研究所,江西省赣州市341000

出　　处：《中华泌尿外科杂志》2015年第3期192-195,共4页Chinese Journal of Urology

基　　金：国家高技术研发计划（863计划）项目（2012AA021100）;江西省“赣鄱英才555丁程”领军人才培养计划项目;江西省科技厅最大科技支撑计划项目（20121BBG70032,20132BAB205007）;江西省教育厅科技落地计划项目（KJLD12044）;江西省卫生厅科技计划项目（20111074,20121095）

摘　　要：目的 总结经阴道自然腔道内镜手术（natural orifice transluminal endoscopic surgery,NOTES）辅助腹腔镜下肾部分切除术的经验,探讨该术式的临床应用价值. 方法 2013年8月至2014年8月收治6例肾肿瘤患者,均为已婚已育女性.年龄30-48岁,中位值37岁.肿瘤直径2.5-6.5 cm,中位值3.5 cm.均行经阴道NOTES辅助腹腔镜下肾部分切除术.全麻,截石位,患侧腰部垫高约60°.于两侧脐缘内置入工作套管及操作器械,自阴道后穹窿置入套管及5.4 mm 0°加长远端可弯曲（四方向）腹腔镜.游离肾脏并分别显露肾动、静脉.6例分别采用肾动脉完全阻断、肾段动脉阻断、肾动脉不阻断方法,距肿瘤边缘0.5 cm完整切除肿瘤,全层或分层连续缝合肾实质创面.标本装袋后自阴道后穹窿切口取出. 结果 本组6例均未中转开放手术或新增工作通道,其中5例手术顺利完成,1例肾上极肿瘤因开放肾动脉后肾实质创面持续出血改行根治性肾切除术.行肾动脉完全阻断3例,热缺血时间分别为20、25、28 min;肾段动脉阻断2例,阻断时间分别为35、40 min;肾动脉未阻断1例.手术时间110-190 min,中位值130 min.术中估计失血量100 - 400 ml,中位值150 ml.术后均无尿瘘发生;术后继发出血1例,保守治疗后痊愈.术后48 h视觉模拟疼痛评分1-3分,中位值2分.术后住院时间4-10d,中位值5d.术后病理报告均为肾透明细胞癌,切缘均阴性.术后随访3-14个月,6例均健康存活,无肿瘤复发.术后1个月瘢痕评估问卷评分为39-48分,中位值42分.6例术后3个月均恢复正常性生活,女性性功能指数为26.2 - 30.4分,中位值27.7分. 结论 经阴道NOTES辅助腹腔镜下肾部分切除术安全、可行,术后疼痛轻,恢复快,疗效确切,美容效果佳,且不影响术后性功能.Objective To describe the initial clinical experience of transvaginal NOTES-assisted laparoscopy for partial nephrectomy,and evaluate its feasibility and efficacy.Methods Between Aug.2013 and Aug.2014,6 females underwent transvaginal NOTES-assisted laparoscopic partial nephrectomy.All patients were married and delivered.The median age was 37 （30 to 48） yrs.The median tumour size was 3.5 （2.5 to 6.5） cm.Under general anesthesia,the patient was placed in the lithotomy position with the affected side elevated by 60°.Two trocars were placed at the medial margin on both sides of umbilicus.A trocar was placed through the vagina into the abdominal cavity under the direct vision from a flexible-tip 5.4 mm 0° laparoscope.The patients underwent surgeries with main renal artery clamping,segmental renal artery clamping and renal artery unclamping,respectively.The mass was excised using the laparoscopic scissors maintaining a 0.5 cm margin.The inner layer was sutured for closing the collecting system and the second layer was sutured for closing the renal parenchyma with the Quill self-retaining suture.Specimen was placed inside a homemade bag and removed through the posterior vaginal fornix incision.Results Five procedures were completed successfully.One patient with a right upper-pole tumor was converted to radical nephrectomy for continuous bleeding after removing the bulldog clip.All the procedures were finished without conversion to conventional laparoscopy and with no additional trocar.The warm ischaemia time （WIT） was 20,25 and 28 min for the three patients who underwent surgeries with main renal artery clamping,respectively.The WIT was 35 and 40 min for the two patients who underwent surgeries with segmental renal artery clamping,respectively.One patient underwent surgeries with renal artery unclamping.The median operating time was 130 （110 to 190） min.The estimated blood loss was 150 （100 to 400） ml.One patient who was subjected to postoperative bleeding recovered with conservative treatment.Ther

关 键 词：经自然腔道内镜手术 经阴道途径 肾部分切除术 

分 类 号：R737.11[医药卫生—肿瘤]