泌尿外科经脐、经腰单孔腹腔镜手术的初步对比及技术(附166例报道)
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摘要
目的:初步探讨泌尿外科经脐、经腰单孔腹腔镜手术及技巧改良。方法:2011年6月~2016年11月,共行单孔腹腔镜泌尿外科手术166例(193侧)。其中男∶女为58∶108,平均年龄31(2~53)岁,平均体质指数20.4(16.5~26.8)kg/m~2。手术途径:经脐129例、经腰37例。行肾上腺和肾脏等疾病手术98例,输尿管、膀胱疾病手术32例,性腺、精索手术36例;同时行双侧病变手术27例;肿瘤病变33例,需缝合病例48例。均使用自制"1环3通道"装置,10 mm或5 mm 30°腹腔镜,普通直型腹腔镜器械完成手术;镜下打结(48例)及双J管留置(41例),均用改良法完成,28例用带线缝针牵引法增加术野暴露。结果:5例分别中转2孔腹腔镜或3孔腹腔镜,其余均成功完成。平均手术时间:95(15~310)min,平均手术失血量45(5~600)ml,平均住院时间5.5(1~12)d。术后止痛剂应用经脐51/129人,经腰26/37人。围手术期并发症12人次。157例获得1个月~5年随访。切口愈合满意,术后1~3个月温哥华瘢痕平均评分:经脐途径3.3分(3~5分),经腰途径4.2分(4~7分)。结论:用自制"1环3通道装置"及普通器械,行大多数泌尿外科单孔腹腔镜手术,安全可行;应用改良留置双J管法、改良镜下打结法、带线缝针牵引法增加暴露,可提高手术效率;术后切口美容效果和术后疼痛程度经脐途径优于经腰途径,U-LESS更适合有美容需求及双侧病变的患者。避免肠道干扰的问题上,经腰优于经脐途径。LESS术式学习曲线长,仍需不断技术改良和更多手术经验积累。
Objective:To compare the umbilical laparoendoscopic single-site surgery and retroperitioneal laparoendoscopic single-site surgery in urology.Methods:From June 2011 to November 2016,166patients(193sides)were subjected to laparoendoscopic single-site surgery(LESS)in our institute.There were 58 males and 108 females,and the average age was 31years(2-53years).The average body mass index(BMI)was 20.4(16.5-26.8).The transumbilical approach was used in 129 cases,and translumbar approach in 37 cases.There were 98 cases for adrenal and renal surgery,32 cases for ureter and bladder surgery,36 cases for gonad and spermatic cord surgery.There were 27 cases of bilateral lesions,33 cases of neoplastic lesions,and 48 cases were given suture.All the surgical procedures were performed by self-made "1-ring 3-channel" device,10 mm or 5 mm 30°laparoscope and general laparoscopic instrument.Laparoscopic knot(48cases)and D-J stent implantation(41cases)were completed by modified method.There were 28 cases receiving needle thread traction to increase the surgical exposure.Results:All the operations were completed successfully.Among them,5cases were conversed to 2-3site laparoscopic surgery.The average operative time was 95min(15-335min),and the average blood loss was 45mL(5-600mL).The average postoperative hospital stay was 5.5d(1-12d).Seventy-three patients were given analgesic postoperatively.Perioperative complications occurred in 12 patients.157cases were followed up for 1month to 5years.They were satisfied with incision healing.The Vancouver scar score was 3.3points for the transumbilical approach,and 4.2points for the translumbar approach.Conclusions:It is safe to use self-made "1ring3channel" and common instrument to implement urological single-site laparoscopic surgery.The modified method for indwelling D-J tube,laparoscopic knot,and the needle thread traction could improve the efficiency of LESS.The transumbilical surgery has a better cosmetic effect and less pain than the other,more suitable for woman and bilateral lesions.And the translumlar LESS has an advantage on avoiding intestinal disturbances.All in all,the learning curve of LESS is long and the continuous technical improvement and more experience are needed.
Objective:To compare the umbilical laparoendoscopic single-site surgery and retroperitioneal laparoendoscopic single-site surgery in urology.Methods:From June 2011 to November 2016,166patients(193sides)were subjected to laparoendoscopic single-site surgery(LESS)in our institute.There were 58 males and 108 females,and the average age was 31years(2-53years).The average body mass index(BMI)was 20.4(16.5-26.8).The transumbilical approach was used in 129 cases,and translumbar approach in 37 cases.There were 98 cases for adrenal and renal surgery,32 cases for ureter and bladder surgery,36 cases for gonad and spermatic cord surgery.There were 27 cases of bilateral lesions,33 cases of neoplastic lesions,and 48 cases were given suture.All the surgical procedures were performed by self-made "1-ring 3-channel" device,10 mm or 5 mm 30°laparoscope and general laparoscopic instrument.Laparoscopic knot(48cases)and D-J stent implantation(41cases)were completed by modified method.There were 28 cases receiving needle thread traction to increase the surgical exposure.Results:All the operations were completed successfully.Among them,5cases were conversed to 2-3site laparoscopic surgery.The average operative time was 95min(15-335min),and the average blood loss was 45mL(5-600mL).The average postoperative hospital stay was 5.5d(1-12d).Seventy-three patients were given analgesic postoperatively.Perioperative complications occurred in 12 patients.157cases were followed up for 1month to 5years.They were satisfied with incision healing.The Vancouver scar score was 3.3points for the transumbilical approach,and 4.2points for the translumbar approach.Conclusions:It is safe to use self-made "1ring3channel" and common instrument to implement urological single-site laparoscopic surgery.The modified method for indwelling D-J tube,laparoscopic knot,and the needle thread traction could improve the efficiency of LESS.The transumbilical surgery has a better cosmetic effect and less pain than the other,more suitable for woman and bilateral lesions.And the translumlar LESS has an advantage on avoiding intestinal disturbances.All in all,the learning curve of LESS is long and the continuous technical improvement and more experience are needed.
引文
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[2]Merseburger AS,Herrmann TR,Shariat SF,et al.EAU guidelines on robotic and single-site surgery in urology.Eur Urol,2013,64(2):277-291.
[3]余闫宏,杨峻峰,何正宇,等.青少年儿童经脐单孔腹腔镜肾盂离断成型术3例报道.微创泌尿外科杂志,2016,5(5):288-291.
[4]Ahuja RB,Chatterjee P.Comparative efficacy of intralesional verapamil hydrochloride and triamcinolone acetonide in hypertrophic scars and keloids.Burns,2014,40(4):583-588.
[5]Rane A,Rao PP,Rao SP,et al.Clinical evaluation of a novel laparoscopic port(RGPortTM)in urology and evolution of the single laparoscopic port procedure(SLAPP).J Endourol,2007,21(1):A22.
[6]Gettman MT,White WM,Aron M,et al.Where do we really stand with LESS and NOTES?Eur Urol,2011,59(2):231-234.
[7]Ramirez D,Maurice MJ,Kaouk JH.Robotic singleport surgery:paving the way for the future.Urology,2016,95(1):5-10.
[8]孙颖浩,王林辉,杨波.经脐单孔多通道腹腔镜下肾切除术三例.中华外科杂志,2009,47(1):1709-1711.
[9]张旭,马鑫,李宏召,等.单孔后腹腔镜解剖性肾上腺切除术5例报告.临床泌尿外科杂志,2009,24(9):647-650.
[10]王林辉,刘冰,杨庆,等.泌尿外科单孔腹腔镜手术209例临床应用分析.中华泌尿外科杂志,2012,33(10):757-762.
[11]Sato F,Nakagawa K,Kawauchi A,et al.Laparoendoscopic single-site surgeries:A multicenter experience of 469cases in Japan.Int J Urol,2017,24(1):69-74.
[2]Merseburger AS,Herrmann TR,Shariat SF,et al.EAU guidelines on robotic and single-site surgery in urology.Eur Urol,2013,64(2):277-291.
[3]余闫宏,杨峻峰,何正宇,等.青少年儿童经脐单孔腹腔镜肾盂离断成型术3例报道.微创泌尿外科杂志,2016,5(5):288-291.
[4]Ahuja RB,Chatterjee P.Comparative efficacy of intralesional verapamil hydrochloride and triamcinolone acetonide in hypertrophic scars and keloids.Burns,2014,40(4):583-588.
[5]Rane A,Rao PP,Rao SP,et al.Clinical evaluation of a novel laparoscopic port(RGPortTM)in urology and evolution of the single laparoscopic port procedure(SLAPP).J Endourol,2007,21(1):A22.
[6]Gettman MT,White WM,Aron M,et al.Where do we really stand with LESS and NOTES?Eur Urol,2011,59(2):231-234.
[7]Ramirez D,Maurice MJ,Kaouk JH.Robotic singleport surgery:paving the way for the future.Urology,2016,95(1):5-10.
[8]孙颖浩,王林辉,杨波.经脐单孔多通道腹腔镜下肾切除术三例.中华外科杂志,2009,47(1):1709-1711.
[9]张旭,马鑫,李宏召,等.单孔后腹腔镜解剖性肾上腺切除术5例报告.临床泌尿外科杂志,2009,24(9):647-650.
[10]王林辉,刘冰,杨庆,等.泌尿外科单孔腹腔镜手术209例临床应用分析.中华泌尿外科杂志,2012,33(10):757-762.
[11]Sato F,Nakagawa K,Kawauchi A,et al.Laparoendoscopic single-site surgeries:A multicenter experience of 469cases in Japan.Int J Urol,2017,24(1):69-74.