早期序贯开放血流法在T1b期肾肿瘤行腹腔镜肾部分切除术中的初步应用  

Application of early sequential unclamping method in laparoscopic partial nephrectomy for patients with T1b renal tumor

作　　者：刘溪[1] 潘秀武 曲发军[1] 张向民[3] 褚健 干思舜[1] 储传敏[1] 叶剑青[1] 王林辉[2] 崔心刚[1] Liu Xi;Pan Xiuwu;Qu Fajun;Zhang Xiangmin;Chu Jian;Can Sishun;Chu Chuanmin;Ye Jianqing;Wang Linhui;Cui Xingang(Department of Urology Eastern Hepatobiliary Surgery Hospital,Second Military Medical University,Shanghai 201805,China)

机构地区：[1]第二军医大学东方肝胆外科医院泌尿外科,上海201805 [2]第二军医大学长征医院泌尿外科 [3]第二军医大学公利医院泌尿外科

出　　处：《中华泌尿外科杂志》2018年第8期577-581,共5页Chinese Journal of Urology

摘　　要：目的探讨早期序贯开放血流法在腹腔镜肾部分切除术中的应用价值。方法回顾性分析2017年4—10月我院对8例T1b期肾肿瘤运用早期序贯开放血流法行腹腔镜肾部分切除术的临床资料。男5例，女3例；年龄43～70岁，平均56．4岁；肿瘤位于左侧3例，右侧5例；肿瘤直径4．6～6．4cm，平均5．6cm。术前R．E．N．A．L．评分7～10分，平均8．8分；美国麻醉医师协会评分l～2分，平均1．4分。术前血肌酐72．1～104．2μmol/L，平均89．5μmol／L；术前患肾肾小球滤过滤（GFR）水平40．4—62．3ml／min，平均55．5ml／min。患者经后腹腔入路，采用早期序贯开放血流法行肾部分切除术：根据术前CT动脉造影结果，常规分离肾动脉主干及分支，在肿瘤切除前，序贯阻断肾肿瘤所在肾段分支动脉及肾动脉主干。切除肿瘤后，完成第1层裸露的肾创面血管和集合系统残端的缝合修补，随后放开肾动脉主干阻断钳，恢复大部分肾脏血供，保持肿瘤供血分支动脉继续阻断。然后用倒剌线缘对缘连续缝合的方式缝合肾创缘，使肾脏创面基本对合，完成第2层缝合后开放分支动脉供血，继续连续缝合第3层并使缝线与第2层缝线间交叉，使止血效果确切。结果8例手术均顺利完成，无中转开放手术病例。手术时间90～180min，平均132．5min；术中出血量100～200ml，平均142．5ml；完全热缺血时间为12．0～20．0min，平均15．5min。8例术中及术后均未输血，手术切缘阴性。术后病理诊断7例为透明细胞癌，1例乳头状细胞癌。术后未发生漏尿、切口感染、高热等并发症，引流管拔除时间为术后3～5d，平均3．5d；术后住院时间4～6d，平均4．8d。术后1个月血肌酐83．6—101．2μmol／L，平均94．0μmol／L；术后患肾GFR水平43．2～59．6ml／min，平均52．3ml/min，分别与术前比较肾功能未见明显损害（P=0．181，P=0Objective To analyze the value of early sequential unclamping method in laparoscopic partial nephrectomy. Methods From April 2017 to October 2017, a total of 8 cases of renal tumor patients by early sequential unclamping method of laparoscopic partial nephrectomy （ LPN ） were reviewed, with 5 males and 3 females and average age of 56.4 years （43 -70 years）. Three cases of renal tumor were located on the left side, 5 cases on the right side. The mean tumor diameter was 5.6 （4.6 - 6.4） cm. The preoperative R. E. N. A. L. score was 8. 8 （7 - 10）, and the mean ASA score was 1. 4 （1 -2）. Preoperative serum creatinine level was 89.5 （72.1 -104.2） μmol/L, and the GFR level of the kidney with tumor before operation was 55. 5 （40.4 -62.3） ml/min. The early sequential unclamping method was used for retroperitoneal laparoscopic partial nephrectomy： according to the preoperative CTA results, the mainbranches and branches of the renal artery were routinely separated. Before the tumor resection, the branches of renal artery and the main renal artery were sequentially blocked. After removal of the tumor, the first layer of bare kidney wound blood vessels and collection system were sutured and repaired. Then released the main renal artery occlusion clamp, restored most of the blood supply to the kidney, but kept the tumor-specific segmental renal artery blocked. Continuous suture of the kidney created a rough combination of the renal wound. After second layers of suture completed, unelamped the segmental renal artery and sutured the renal wound again, made the third layers of suture intersecting with the second seam suture to strengthen the hemostatic effect. Results All the 8 patients were performed LPN with early sequential unclamping method successfully. The average operative time was 132.5 （90- 180） min, the intraoperative blood loss was 142.5 （100-200） ml, the completely warm ischemia time was 15.5 （12.0 -20.0） rain, and no blood transfusion was performed intraoperatively and posto

关 键 词：肾肿瘤 肾部分切除术 肾动脉分支阻断 早期开放血流 热缺血时间 

分 类 号：R737.11[医药卫生—肿瘤]