腹腔镜结直肠癌NOSES术中左结肠动脉的外科解剖与保留技巧

目的观察腹腔镜结直肠癌经自然腔道取标本手术（NOSES）中左结肠动脉（LCA）的外科解剖，探讨保留LCA的手术技巧及临床疗效。 方法回顾性分析2017年1月至2021年12月于四川省肿瘤医院施行腹腔镜下保留LCA的结直肠癌NOSES手术85例患者的临床资料，其中54例术中对LCA的外科解剖进行了观察与记录，结合手术录像分析LCA的外科走行与解剖分型，探讨保留LCA的操作技巧和临床效果。 结果所有病例LCA均从肠系膜下动脉（IMA）左侧发出，LCA发出处至IMA根部的平均距离为（3.5±1.1）cm；75.9%（41/54）病例LCA向外走行时自肠系膜下静脉（IMV）前方与其相交，24.1%（13/54）自IMV后方与其相交；LCA自IMA单独发出者（Ⅰ型）23例（42.6%），LCA与乙状结肠动脉（SA）两支共干者（Ⅱ型）9例（16.7%），LCA与SA、直肠上动脉（SRA）三支共干者（Ⅲ型）19例（35.2%），LCA、SRA与两支或两支以上SA多支共干者（Ⅳ型）3例（5.6%），本组未见LCA缺如病例。85例患者均顺利完成手术，其中2例（2.4%）术后出现了吻合口漏，1例经保守治疗痊愈，1例进行了回肠造瘘手术；无围手术期死亡病例；术后平均住院时间（10.4±3.4）d。 结论LCA的外科走行多样，解剖变异复杂；腹腔镜下保留LCA需要较高的手术技巧、精细解剖、耐心操作。腹腔镜结直肠癌术中保留LCA操作与NOSES技术相结合，有望将损伤控制、功能保护、微创治疗的外科理念发挥到极致。

Surgical anatomy and preservation techniques of left colic artery in laparoscopic colorectal cancer NOSES surgery

ObjectiveTo observe the surgical anatomy of the left colic artery (LCA) during laparoscopic natural orifice specimen extraction surgery (NOSES) for colorectal cancer and to explore the preservation techniques during surgery and its clinical efficacy on patients. MethodsThe clinical data of 85 patients with colorectal cancer who underwent laparoscopic LCA-preserving NOSES operation in Sichuan Cancer Hospital from January 2017 to December 2021 were retrospectively analyzed. Among them, LCA anatomy of 54 patients was observed and recorded, combined with the operation video, the anatomical course and surgical classification of LCA were analyzed, and the operation skills and clinical effect of preserving LCA were discussed. ResultsFrom all cases, we observed that the LCA emanated from the left side of the inferior mesenteric artery (IMA), and the average distance was about (3.5±1.1) cm from the root of the IMA to the emanation of LCA; Among them, 75.9% (41/54) cases, the LCA intersected in front of the IMV when it traveled outward, and 24.1% (13/54) cases crossed from the rear; twenty-three cases had the LCA branching from the IMA alone (type Ⅰ, 42.6%); nine cases had the LCA co-truncating with the sigmoid artery (SA) (type Ⅱ, 16.7%), nineteen cases had the LCA co-truncating with the superior rectal artery (SRA) and SA (type Ⅲ, 35.2%), and 3 cases had the LCA co-truncating with SRA and two or more SA (type Ⅳ, 5.6%). No absence of LCA was found in this group. All operations performed on 85 patients were successfully completed. Two patients (2.4%) developed anastomotic leakage after surgery, one was cured by conservative treatment, and the other underwent ileostomy. No mortality occurred. The average hospital stay after surgery was (10.4±3.4) days. ConclusionsThe surgical route of LCA is diverse, and its anatomical variation is complex. Preservation of LCA during laparoscopic surgery requires high surgical skills. However, the combination of LCA-preserving operation and NOSES technology during laparoscopic colorectal cancer surgery is expected to maximize the surgical concepts of damage control, function protection, and minimally invasion.