腹腔镜低位直肠癌根治腹部无切口经肛切除套入式吻合102例经验

目的探讨腹部无切口经肛门切除标本的腹腔镜低位直肠癌根治套入式吻合术的安全性和可行性及临床疗效。 方法从2010年3月至2017年12月对102例低位直肠癌行腹腔镜下根治经肛门切除行套入式吻合保肛术，男43例，女59例。年龄36～81岁(平均59.6岁)。肿瘤距肛缘5～7 cm 85例，4 cm 17例，术前评估T₁N₀M₀ 79例，T₂N₀M₀ 23例。采用中间入路用超声刀沿乙状结肠系膜根部游离并裸化肠系膜下动静脉根部后，施夹并切断。按TME原则，游离直肠至肛管直肠环达肿瘤远端3～5 cm。会阴部手术距齿状线上2 cm处环型切开，沿黏膜下锐性向上剥离至提肛肌平面切断直肠，将直肠及远端乙状结肠一并从肛门移出体外切除，行套入式近端结肠全层与直肠黏膜及肠黏膜下吻合。 结果本组102例，手术平均时间为179 min，平均检出淋巴结13枚，术后发生吻合口漏3例(2.9%)行临时结肠造口，3个月后还纳愈合。吻合口狭窄2例(1.9%)，经扩张后狭窄解除。术后病理为T₁～T₂N₀M₀ 49例，T₂N₁M₀ 53例。术后12个月肛门功能，Kirwan分级1级占94.1%，肛门功能基本恢复到正常。术后随访6～84月，平均45个月，局部肿瘤复发4例(3.9%)，生存满3年以上67例。 结论腹腔镜低位直肠癌根治腹部无切口经肛门切除套入式吻合保肛术，是安全可行，真正达到腹部无手术切口、无瘢痕、美容美观、完全微创的最佳效果，其远期疗效待进一步随访观察。

Laparoscopic radical resection of low rectal cancer with telescopic anastomosis through transanal resection without abdominal incisions,report of 102 cases

ObjectiveTo investigate the safety, feasibility and clinical outcome of laparoscopic radical resection of low rectal cancer with telescopic anastomosis through transanal resection without abdominal incisions. MethodsFrom Mar 2010 to Dec 2017, 102 patients with low rectal cancers, including 43 males and 59 females with an average age of 59.6 years (ranging from 36 to 81 years) underwent laparoscopic radical resection of low rectal cancer with telescopic anastomosis through transanal resection without abdominal incisions. The distance between the anus and inferior margin of the tumor ranged from 5 cm to 7 cm (85 cases) and 4 cm (23 cases). TNM staging showed that 79 patients had cT₁N₀M₀ staging, 23 had cT₂N₀M₀ staging. Through the middle approach, the sigmoid mesentery was freed at the root with an ultrasonic scalpel, and the inferior mesenteric artery and vein was clamped and cut. Following the total mesorectal excision (TME) principle, the rectum was dissected to the anorectal ring and 3-5 cm from the distal end of the tumor. The electric knife was used to cut open the mucosa 1.5-2.0 cm above the dentate line. Sharp dissection was performed along the rectal mucosa, upwards, to peel off the rectal mucosa for 2-4 cm, to reach the levator ani muscles, and the rectum was cut circularly. The rectal tumor and distal sigmoid colon were removed from the anus together, then telescopic anastomosis of proximal sigmoid colon and the distal colon and rectal muscle sheath were performed. ResultsAll of 102 patients received successful laparoscopic surgery without conversion. The average operation time was 179 min and the average harvested lymph nodes was 13. There were 3 cases (2.9%) of stoma leakage, who were cured by temporary colostomy and closure of the stoma 3 months later. The postoperative follow-up ranged from 6 to 84 months (average of 45 months), with 2 cases (1.9%) of stoma stenosis who received expansion treatment. Postoperative pathological results showed that 49 patients had pT_1-2N₀M₀ staging, 53 had pT₂N₁M₀ staging. Twelve months after surgery, 94.1% patients achieved anal function Kirwan grade 1, indicating that their anal function returned to normal. There were 4 cases (3.9%) of local recurrence within 3 years after surgery, with 100% 3-years-survival. ConclusionLaparoscopic radical resection of low rectal cancer with telescopic anastomosis through transanal resection without abdominal incisions is safe, reliable and mini-invasive, without incision and scar on the abdominal wall with satisfactory clinical outcome.