基于肾上腺血管解剖的后腹腔镜肾上腺切除技术的改进及临床应用  

A modified technique for retroperitoneal laparoscopic adrenalectomy based on adrenal vascular anatomy

作　　者：周昱霖[1] 唐朝朋[2] 徐振宇[2] 位志峰[2] 徐晓峰[2] 董杰[2] 张征宇[2] 葛京平[2] 周文泉[2] ZHOU Yu-lin TANG Chao-peng XU Zhen-yu(Department of Urology, the Affiliated People＇ s Hospital of Jiangsu University, Zhenfiang 212002, Chi- na Nanjing General Hospital of PLA Nanjing Military Command)

机构地区：[1]江苏大学附属人民医院,江苏镇江212002 [2]南京军区南京总医院

出　　处：《腹腔镜外科杂志》2017年第7期481-485,共5页Journal of Laparoscopic Surgery

摘　　要：目的:基于对肾上腺血管解剖的理解,探讨后腹腔镜肾上腺切除术的新技术。方法:2013年12月至2015年5月共收治179例肾上腺肿瘤患者,其中男92例,女87例;肿瘤位于右侧88例,左侧91例;患者12~79岁,平均(47.8±9.8)岁;肿瘤直径0.8~11.5 cm,平均(2.8±1.3)cm。根据患者病情完善术前准备后均由同一术者根据以下策略行后腹腔镜肾上腺切除术:(1)腹膜后空间建立后沿腰大肌表面游离并纵行打开肾筋膜直至膈肌脚,寻及膈下动脉并结扎切断肾上腺上动脉;(2)寻及肾动脉,紧贴肾动脉及肾上极内侧缘夹角向深面游离,结扎肾上腺中、下动脉;(3)通过肾动脉及肾脏内侧缘所形成的"中央静脉三角"寻找肾上腺中央静脉并离断;(4)在肾脏、肾上腺之间游离,到达肾前融合筋膜层面,将肾上腺与肾脏重叠部分分离;(5)离断肾上腺周围相连的结缔组织,完整切除肾上腺。结果:178例手术获得成功,1例中转开放手术;手术时间12~68 min,平均(30.2±10.3)min;出血量10~110 ml,平均(20.6±12.7)ml;术后住院1.5~3.9 d,平均(2.3±0.8)d;2例术中出现腹膜损伤,术后随访期间未见肿瘤复发及转移。结论:此操作方法更加直接的处理肾上腺血供,减少了出血的几率,游离面较少,根据肾上腺解剖关系不用刻意寻找肾上腺肿瘤,操作更加省时、简单。Objective： To investigate a modified technique for retroperitoneal laparoscopic adrenalectomy based on adrenal vascular anatomy. Methods： The clinical data of 179 patients（ 92 males and 87 females） with adrenal tumors from Dec. 2013 to May 2015 were analyzed retrospectively. The average age was（ 47. 8 ± 9. 8） years（ ranging from 12 to 79）. Ninety-one cases had left-located tumor and 88 cases had right-located tumor. The tumor diameter was（ 2. 8 ± 1. 3） cm in average（ ranging from 0. 8 to 11. 5 cm）. All patients underwent retroperitoneal laparoscopic adrenalectomy according to the following protocol：（ 1） After the retroperitoneal working space was created,Gerota fascia was dissected near the diaphragm to the crura of diaphragm,then the superior suprarenal artery was exposed and coagulated.（ 2） To dissect the middle and inferior suprarenal artery,surgeons dissected along with the plane between the renal artery and the inner margin of upper pole of kidney in order to divide the connective tissues that contained middle and inferior adrenal artery.（ 3） Then central adrenal vein was dissected and ligated in the triangle consisting of renal artery,inner margin of kidney and central adrenal vein.（ 4） Dissection was made between kidney and adrenal gland till the prerenal fusion fascia level.（ 5） Finally,the tumor was extracted after the surrounding tissues were separated. Results： All surgeries were successful with one conversion to open surgery. The average operative time was（ 30. 2 ± 10. 3） min（ ranging from 12 to 68 min）,and the mean blood loss was（ 20. 6 ± 12. 7） ml（ ranging from 10 to 110 ml）. All patients were discharged from the hospital in 1. 5 to 3. 9 d after surgery,the average postoperative hospital stay was（ 2. 3 ± 0. 8） d. Peritoneum perforation occurred in two cases in operation but no relapse or metastasis was found during the follow-up. Conclusions： This novel technique can dissect blood supply directly and reduce the risk of bleedi

关 键 词：肾上腺肿瘤 肾上腺切除术 腹腔镜检查 腹膜后路径 解剖 

分 类 号：R736.6[医药卫生—肿瘤]