【作者】 孙文超；

【导师】 张大宏；

【作者基本信息】 浙江大学 ， 外科学， 2007， 硕士

【摘要】 背景与目的近年来，越来越多的肾细胞癌患者通过施行保留肾单位手术而获得治愈。有证据表明保留肾单位手术在治疗肾脏小肿瘤方面与根治性肾切除有着同样的肿瘤清除效果，同时还能最大限度地减少肾功能的损失。所以，保留肾单位手术已经成为治疗直径小于4cm肾脏肿瘤的首选方法。腹腔镜保留肾单位肾肿瘤切除术将微创技术与保留肾单位手术的优点集于一身，对于那些拟行保肾手术治疗肾肿瘤的患者而言，保留肾单位的腹腔镜手术是可尝试之选择。有效减少术中出血是开展腹腔镜保留肾单位手术的难点。随着时间推移，大量先进技术层出不穷。常用方法有肾蒂钳、弹性吊带、双极电凝、氩气凝固及TissueLink刀等，各有优缺点。我们使用特制的肾蒂阻断钳控制肾脏血流，通过锐性切除肿瘤以及创面直接缝合的方法行保留肾单位手术，取得良好的治疗效果。临床资料和研究方法临床资料2003年6月至2006年6月，我们共收治肾外生性实性肿瘤患者21例。男9例，女12例。年龄29～81岁，平均55.8岁。肿瘤位于左侧13例，右侧8例。肾细胞癌8例，肿瘤直径2.0～5.0cm，平均2.5cm；肾错构瘤12例，肿瘤直径3.0～5.5cm，平均4.1cm；肾嗜酸细胞瘤1例。其中1例肾错构瘤继发出血。手术方法经腹腔路径行保留肾单位的腹腔镜肾肿瘤切除术，手术在无损伤钳钳夹肾蒂控制血管后距肿瘤0.5～1.0cm正常实质处锐性切除，创面连续缝合止血。结果21例手术均成功，无一例中转开放。手术时间70～150min，平均104min。肾蒂阻断时间11～32min，平均21min。术中出血量20～700ml，平均118.3ml。8例肾细胞癌患者病理检查示切缘阴性。21例术后无尿瘘、无继发出血，肾功能未见异常。2～4d肛门排气，平卧1周出院。随访1～24个月，21例B超复查、11例CT检查肿瘤无复发，IVU复查肾显影良好。结论可靠的肾血管控制是腹腔镜下行保留肾单位的肾肿瘤切除术的基本保证，无烟雾锐性切除肿瘤和创面的缝合处理能有效减少肾缺血时间。本手术创伤小、出血少、痛苦少、并发症少、恢复快，能有效切除肿瘤和保留或保护肾功能。更多还原

【Abstract】 BACKGROUND AND PURPOSEWithin a short period, nephron-sparing surgery has been evaluated and used in patients with small renal tumors including renal cell carcinoma. Recent evidence has confirmed that partial nephrectomy achieves cancer control comparable to that of radical nephrectomy for small tumors while preserving renal function. Thus, partial nephrectomy has emerged as a standard option for managing tumors less than 4 cm. Laparoscopic partial nephrectomy which combines the benefits of nephron-sparing surgery with a minimally invasive approach, may significantly decrease analgesic requirement and expedite convalescence after surgery. For patients who are candidates for nephron-sparing surgery, laparoscopic surgery is a viable treatment alternative.Various techniques have been introduced to reduce blood loss during laparoscopic partial nephrectomy. The efficiency for controlling vigorous bleeding has not gained widespread acceptance. We use self-made laparoscopic renal pedicle clamp to achieve en bloc control of renal hilum. Then laparoscopic partial nephrectomy is performed with sharp resection of the renal lesion and precise suture repair of renal parenchyma. We report our single institutional experience in 21 patients.DATA AND TECHNIQUESCLINICAL DATAFrom June 2003 to June 2006, transperitoneal laparoscopic nephron-sparing surgery was performed to 21 patients with small exophytic solid renal masses. Of the 9 male and 12 female patients, 13 cases had renal lesion on the left side and 8 on the right. Mean patient age was 55.8 years (range 29 to 81). The average tumor size of renal cell carcinoma in diameter was 2.5 cm (range 2.0～5.0). The average size of angiomyolipoma in diameter was 4.1 cm (range 3.0 to 5.5). Meanwhile, histopathologic study confirmed renal oncocytoma in 1 case. Additionally, 1 case of hamartoma had secondary bleeding.TECHNIQUES OF SURGERYAll patients underwent laparoscopic partial nephrectomy using a transperitoneal approach and hilar clamping. Self-made laparoscopic renal pedicle clamp was used to obtain en bloc control of renal hilum. The tumor was excised with a rim of 0.5-1.0 cm normal parenchyma using a laparoscopic shear, and hemostasis was achieved by intracorporeal pure free hand running suture and knot tying.RESULTSAll procedures were completed laparoscopically and no conversion to open surgery was required. Mean operating time was 104 minutes (range 70 to 150). Mean warm ischemia time was 21 minutes (range 11 to 32). Mean blood loss was 118.3 ml (range 20 to 700). Hospital stay averaged 7 days. Renal cell carcinoma was confirmed on pathological examination in 8 patients, and all had negative surgical margins for cancer. During a follow-up of 1 to 24 months, Neither distant nor local recurrences were observed by ultrasonography, IVU or CT scan.CONCLUSIONSLaparoscopic partial nephrectomy can be performed safely and efficiently for select patients. Reliable renal vascular control is the key point of this operation. Sharp resection and precise suture repair of renal parenchyma are able to decrease the warm ischemia time.更多还原