摘要目的:评价耻骨上辅助单孔腹腔镜肾切除术(suprapubic-assisted laparoendoscopic single-site surgery nephrectomy,SA-LESS-N)的安全性、可行性和有效性。方法:共收治90例患者,男72例,女18例,年龄20~78岁,平均51.7岁。包括肾积水致无功能肾69例,肾癌19例,肾结核2例。手术在全麻下进行,患者取健侧70°卧位,脐缘置入两个Trocar及操作器械,自耻骨联合患侧阴毛覆盖处置入一Trocar及腹腔镜。手术方法同标准腹腔镜手术。切除标本装袋,延长耻骨上切口或粉碎后取出。结果:除5例患者术中中转标准腹腔镜手术和1例中转开放手术外,其余手术均顺利完成。平均手术时间:单纯性肾切除术110(95~175)min,根治性肾切除术90(75~160)min。平均失血量155(55~300)ml。平均术后住院时间7.2(5~8)d。术后疼痛轻,切口愈合良好,手术瘢痕隐蔽,美容效果佳。结论:SA-LESS-N安全、可行、有效,术后患者疼痛轻、美容效果佳,值得临床应用。
Abstract：Objective:To describe the initial clinical experience of suprapubic-assisted laparoendoscopic single-site surgery nephrectomy (SA-LESS-N) in Urology, and evaluate its safety, feasibility and efficacy. Methods:Ninety consecutive patients including 72males and 18 females, with a mean age of 51.7 years (range 20 to 78), were subjected to SA-LESS-N in our center. There were 69 non-functioning kidneys, 19 renal carcinomas, and 2 tuberculosis kidneys in our study. Under general anesthesia, the patients were positioned in lateral decubitus with affected side elevated 70°.One 5- and 10-mm (or two 5-mm) trocars were inserted into the umbilical edge. A 10-or 5-mm trocar was inserted into abdominal cavity below the pubic hairline, through which a 10-mm 30° or 5-mm 0° laparoscope was placed. The operation was same as that of standard laparoscopy.The specimens were removed after the incisions below the pubic hairline were enlarged or they were crashed. Results:SA-LESS-N was successfully completed in 84 patients.Five patients required conversion to standard laparoscopy because of intraoperative bleeding (n=4), and failure to progress (n=1). One patient underwent open conversion because of gradual bleeding during the dissection of dense adhesive renal pedicle due to infection and fibrosis. The mean operative time for simple nephrectomy 110(range from 95 to 175)mins,radical nephrectomy 90(range from 75 to 160) mins. The mean blood loss was 155 (range from 55 to 300) ml. Hospitalization duration was between 5 and 8 days with a mean postoperative stay of 7.2 days. The mean follow-up of 16.2 (range from 2 to 35) months showed hidden umbilicus scar. The suprapubic scar was not detectable because of the pubic hairs. Conclusions:SA-LESS-N appears to be feasible, safe and effective. It would not only lead to improved cosmetic results, but lead to little postoperative pain.
[1]Kaouk JH, Autorino R. Laparoendoscopic single-site surgery (LESS) and nephrectomy: current evidence and future perspectives. Eur Urol, 2012, 62(4):613-616. [2]Raybourn JH 3rd, Rane A, Sundaram CP. Laparoendoscopic single-site surgery for nephrectomy as a feasible alternative to traditional laparoscopy. Urology, 2010, 75(1):100-103. [3]Stolzenburg JU, Hellawell G, Kallidonis P, et al. Laparoendoscopic single-site surgery: early experience with tumor nephrectomy. J Endourol, 2009, 23(8):1287-1292. [4]孙颖浩,王林辉,杨波,等.经脐单孔多通道腹腔镜手术治疗良性肾脏疾病的初步体会.中华泌尿外科杂志, 2009, 30(11):728-730. [5]张旭,马鑫,朱捷,等.经脐单孔腹腔镜肾切除术2例报告.临床泌尿外科杂志, 2009, 24(8):569-571. [6]孙颖浩,那彦群.单孔腹腔镜技术在泌尿外科发展中的难题和对策.中华泌尿外科杂志, 2011, 32(2):77-78. [7]邹晓峰, 张国玺, 袁源湖, 等.耻骨上辅助经脐单孔腹腔镜技术在泌尿外科的应用价值(附57例报告).临床泌尿外科杂志, 2011, 26(7): 481-484. [8]Zou XF, Zhang GX, Yuan YH, et al. Suprapubic-assisted laparoendoscopic single-site surgery (LESS) in urology: our experience. BJU Int, 2013, 112(2): E92-98. [9]Clavien PA, Barkun J, de Oliveira ML, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009, 250:187-196. [10]邹晓峰, 廖云峰, 张国玺, 等.耻骨上辅助经脐单孔腹腔镜上尿路全切除术(附8例报告).临床泌尿外科杂志,2013, 28(6):401-404. [11]Zorn KC, Orvieto MA, Mikhail AA, et al. Solitary ureteral metastases of renal cell carcinoma. Urology, 2006, 68(2):428.e5-7. [12]郑清友, 杨学辉, 杨同君, 等.肾癌输尿管转移(附三例报告).中华泌尿外科杂志,2000, 21(2): 78-80. [13]Tisdale BE, Kapoor A, Hussain A, et al. Intact specimen extraction in laparoscopic nephrectomy procedures: Pfannenstiel versus expanded port site incisions. Urology, 2007, 69(2):241-244. [14]Ponsky LE, Steinway ML, Lengu IJ, et al. A Pfannenstiel single-site nephrectomy and nephroureterectomy: a practical application of laparoendoscopic single-site surgery. Urology, 2009, 74(3):482-485.
