不同入路腹腔镜完整结肠系膜切除术治疗右半结肠癌的临床效果和预后的对比研究

目的研究和比较中间入路、尾侧入路以及尾侧中间联合入路腹腔镜完整结肠系膜切除术（CME）对右半结肠癌患者围手术期和术后累积生存情况。 方法前瞻性单盲选择2016年2月至2019年7月在肇庆市第一人民医院进行腹腔镜右半结肠癌CME的96例患者,用随机数字表法将其分为三组,各32例：中间组（行中间入路）、尾侧组（行尾侧入路）和联合组（行尾侧中间联合入路）。比较三组患者围手术期指标、并发症发生率,Kaplan-Meier生存曲线分析患者术后累积无病生存率（DFS）、总生存率（OS）。 结果中间组、尾侧组分别中转开腹3、1例。尾侧组和联合组手术时间、术中出血量均优于中间组,且联合组优于尾侧组（P<0.05）;联合组肛门排气时间、引流管拔除时间和术后住院时间均显著少于尾侧组和中间组（P<0.05）,并发症总发生率更低（P<0.05）。三组患者术后累积OS和DFS比较,差异无统计学意义（χ²=0.227、0.714,P=0.893、0.700）。 结论腹腔镜右半结肠癌CME术中行尾侧中间联合入路在缩短手术时间、减少术中出血量及降低并发症发生率等方面更具优势,有益于患者术后康复,值得在临床上推广。     

腹腔镜右半结肠癌CME切除术——尾侧中间联合入路

手术遵循完整结肠系膜切除原则。手术过程包括：探查腹腔;自尾侧从末端回肠系膜根部黄白交界线打开系膜,进入右结肠后间隙,向头侧,外侧拓展该间隙,至十二指肠水平;回到传统中间入路,回结肠血管下方打开结肠系膜,与尾侧方向打开的间隙会师;解剖并高位结扎切断回结肠血管、打开肠系膜上静脉血管鞘,清扫外科干,高位结扎切断右结肠血管、中结肠血管右支,继续拓展分离右结肠后间隙、横结肠后间隙,直至胰腺下缘并进入小网膜囊;打开胃结肠韧带,游离结肠肝曲;打开右侧腹膜,完成肠段游离,体外切除标本、重建消化道。     

尾侧联合中间入路与中间入路腹腔镜右半结肠癌根治术的Meta分析

目的:比较尾侧联合中间入路与中间入路腹腔镜右半结肠癌根治术的安全性及临床疗效.方法:计算机检索PubMed、Embase、Cochrane Library、万方、中国知网、维普数据库比较尾侧联合中间入路与中间入路腹腔镜右半结肠癌根治术的随机对照试验或临床对照试验文献,检索日期截至2021年7月,对符合标准的文献提取相关...     

尾侧入路法腹腔镜右半结肠癌根治性切除术的临床体会

目的:观察分析经尾侧入路行腹腔镜右半结肠癌根治性切除术的效果及安全性。方法:选取81例接受腹腔镜根治性切除术的右半结肠癌患者作为研究对象,根据手术入路分为观察组(采用尾侧入路,n=42)与对照组(采用中间入路,n=39)。观察比较两组患者术中出血量、手术时间、肠系膜上静脉出血例数、中转开腹比例、清扫淋巴结数量、术后排气时间、住院时间、术后并发症发生率等指标。结果:观察组手术时间、术中出血量优于对照组(P<0.05);两组肠系膜上静脉出血例数、中转开腹、清扫淋巴结数量、术后排气时间、住院时间差异均无统计学意义(P>0.05)。两组患者均未发生切口感染、吻合口瘘、腹腔脓肿等术后并发症。结论:与中间入路相比,腹腔镜右半结肠癌根治性切除术采用尾侧入路,能缩短手术时间,减少术中出血量,降低手术风险及难度,利于患者的术后康复。     

尾侧中间联合入路与传统中间入路腹腔镜右半结肠癌根治术临床对比研究

目的 探讨尾侧中间联合入路与传统中间入路腹腔镜右半结肠癌完整结肠系膜切除（CME）的技术优劣。方法 前瞻性纳入2017年7月至2018年4月期间于上海交通大学医学院附属瑞金医院胃肠外科（上海市微创外科临床医学中心）行腹腔镜右半结肠癌根治术的病人,根据手术入路分为传统中间入路组（中间组）和尾侧中间联合入路组（尾侧组）,并对比两组病人的临床资料（包括基线情况、围手术期相关指标、术后病理情况、CME完成情况等）。结果 共纳入75例病人,其中中间组35例,尾侧组40例,两组病人基线水平（除CA19-9外）、围手术期相关指标、术后病理情况等差异均无统计学意义,切除肠管长度（24 cm vs.22 cm）、A线长度（9.8 cm vs.9.4 cm）、B线长度（9.0 cm vs.8.5 cm）、切除系膜面积（112.4 cm2 vs.109.0 cm2）、中位淋巴结清扫数（19枚 vs.19枚）、淋巴结清扫合格率（97.1% vs.97.5%）、CME完成率（80% vs.85%）等差异均无统计学意义。肥胖［体重指数（BMI）≥25］为影响CME完成率的独立危险因素（P=0.019）。结论 尾侧中间联合入路与传统中间入路腹腔镜右半结肠癌根治术在安全性、可行性、短期疗效、淋巴结清扫彻底性及CME完成质量方面差异均无统计学意义,但仍需更大样本前瞻性随机对照研究（RCT）予以证实。     

完全中间入路腹腔镜左半结肠癌完整结肠系膜切除3例报告

正腹腔镜左半结肠癌根治术与右半结肠癌根治术相比,具有手术范围广、操作跨度大、解剖相对复杂等特点,对术者技术要求较高。其手术路径一直处于探索阶段。本文回顾性分析2016-04-01—30新疆医科大学第一附属医院胃肠肿瘤外科采用完全中间入路行腹腔镜左半结肠完整结肠系膜切除(CME)的3例左半结肠癌病人的临床资料,探讨完全中间入路腹腔镜左半结肠CME的可行性及技术要点。1资料与方法     

腹腔镜中间入路扩大右半结肠癌D3根治术

Lapareseopic colectomy is commonly performed,but laparoscopic extended right hemicolectomy with D3 lymphadenectomy for cancer located at hepatic flexure of the colon is a complex procedure,even in the ...     

腹腔镜下右半结肠癌CME的争议与焦点

右半结肠癌根治术的预后一直是国内外关注的焦点与热点,目前国际上所认可的和完整系膜切除(CME)和D3淋巴结清扫术两种手术理念,能明显降低患者术后局部复发率,提高生存率及无病生存率等。但对二者术式的选择、手术入路的选择、扩大根治肠段切除和淋巴清扫范围及第6组淋巴结清扫与否等一系列问题,目前还有很多争议。同时随着腹腔镜技术的快速发展,单纯的追求微创理念已逐渐转变成更加规范和更加标准的根治理念。笔者结合长期的实践,推荐个性化手术治疗策略,以尽可能确保手术的安全性和根治的彻底性。     

腹腔镜尾侧入路联合中间翻页式清扫右半结肠癌根治术效果分析

目的 探讨腹腔镜尾侧入路联合中间翻页式清扫(尾侧中间联合入路)右半结肠癌根治术的临床效果。方法 回顾性分析巩义市人民医院普外科2017-11—2020-09行腹腔镜右半结肠癌根治术的60例右半结肠癌患者的临床资料。分为尾侧中间联合入路组(观察组)和传统中间入路组(对照组),各30例。比较2组患者基线资料、术中情况、术后临床指标。随访12个月,统计患者的总生存率和无瘤生存率。结果 2组患者基线资料差异无统计学意义(P>0.05)。观察组患者术中出血量少于对照组,手术时间短于对照组,淋巴结清扫数多于对照组,差异均有统计学意义(P<0.05)。2组患者术后排气时间、进食时间、住院时间、并发症发生率,以及术后随访12个月期间的总生存率、无瘤生存率差异均无统计学意义(P>0.05)。结论 腹腔镜尾侧中间联合入路右半结肠癌根治术患者的术后排气时间、进食时间、住院时间、并发症发生率,以及术后随访12个月期间的总生存率、无瘤生存率等指标,与传统中间入路差异均无统计学意义;但其具有手术时间短、创伤轻、淋巴结清扫数多等优势。     

腹腔镜下CME对右半结肠癌患者的临床治疗效果

目的探讨腹腔镜下完整肠系膜切除术(complete mesenterectomy,CME)治疗右半结肠癌的效果。方法选取2015年5月至2016年5月在我院胃肠外科实施手术治疗的右半结肠癌患者89例进行回顾性研究,根据术中采用手术方法分为微创组43例(腹腔镜下CME手术)和开腹组(传统开腹CME手术)46例,对比两组的手术效果。结果微创组患者的手术时间、出血量、切口长度、肛门排气时间、住院时间均低于开腹组(P<0.05),两组患者的淋巴结清扫数目、阳性淋巴结数目差异无统计学意义(P>0.05);微创组患者的并发症率为20.93%,与开腹组的30.43%比较差异无统计学意义(P>0.05)。结论腔镜下CME治疗右半结肠癌具有手术创伤小、术后恢复快、手术效果可靠。     

Laparoscopic complete mesocolic excision for right colon cancer

Laparoscopic colectomy for colon cancer has become a standard of care, with a number of publications highlighting its safety, improved postoperative recovery, and excellent oncologic outcomes. Complete mesocolic excision, recently reemphasized, is associated with superior oncologic outcomes, although this has not been discussed for laparoscopic surgery. A laparoscopic approach was performed for right colon cancer using a four-trocar technique. The key steps demonstrated are identification and high division of the ileocolic pedicle, medial-to-lateral mobilization of the ascending colon preserving the posterior mesocolic fascia, identification and high division of the right branch of the middle colic artery, mobilization of the greater omentum and hepatic flexure, completion of lateral mobilization of the ascending colon from the retroperitoneum, and mobilization of the small bowel mesentery up to the duodenum. A prospective series of 52 consecutive patients with right colon cancer underwent laparoscopic complete mesocolic excision with high-vessel ligation. Four of the patients required laparoscopic en bloc extended resections for local invasion. The median operative time was 136 min (interquartile range [IQR], 105–167 min), and the median blood loss was 20 ml (IQR, 10–45 ml). The median hospital stay was 3 days (IQR, 3–5 days). All the patients had an R0 oncologic resection with median margins of 12 cm, and a median of 22 lymph nodes (IQR, 18–29 lymph nodes) was retrieved. The median follow-up period was 38 months (IQR, 23–54 months). Of 14 patients with tumor-positive lymph nodes, 2 experienced distant recurrence. There were no local recurrences, but four patients experienced metastatic disease at a median of 37 months (IQR, 22–46 months). The median overall survival time was 38 months (IQR, 23–54 months). The embedded didactic video demonstrates a straight laparoscopic complete mesocolic excision with high-vessel ligation for a patient who had a right colon cancer. Laparoscopic right complete mesocolic excision is a safe and effective procedure associated with excellent 3-year oncologic outcomes and accelerated postoperative recovery.     

腹腔镜下完整结肠系膜切除在左半结肠癌根治术中的应用

目的探讨腹腔镜下完整结肠系膜切除(complete mesocolic excision,CME)在左半结肠癌手术中的应用。方法回顾性分析2010年8月至2014年9月间42例行腹腔镜下 CME 治疗左半结肠癌病人的临床资料。结果本组所有病人手术均获成功,手术时间平均为(112.2±25.3) min,术中出血量平均为(54.4±21.6)ml;手术切除肠管的长度平均为(24.1±5.7)cm,清扫淋巴结数量平均为(18.5±6.2)枚;术后肛门首次排气平均时间为(3.3 ± 1.4)d,平均住院时间为(12.7±3.5)d,术后并发症发生4例,发生率为9.52%,其中切口感染 2例,肺部感染1例,吻合口出血1例,均经保守治疗后恢复。结论腹腔镜下左半结肠癌 CME 手术是安全可行的。     

腹腔镜右半结肠癌CME根治术与策略

相对传统右半结肠癌手术,完整全结肠系膜切除(CME)手术可以提供高质量的手术标本和更多的淋巴结清扫数目。因此,腹腔镜右半结肠癌CME根治术既结合了腔镜手术的微创性又兼具CME手术的肿瘤根治性。右半结肠因解剖结构复杂、比邻器官众多、血管变异等因素,手术难度较大。高质量腹腔镜右半结肠癌CME手术的完成需要术者丰富的腹腔镜操作经验与技巧、扎实的解剖学知识和助手的良好配合。腹腔镜右半结肠癌CME手术目前没有标准的手术方式,因此本文拟从右半结肠CME概念、手术适应证、手术步骤、外科操作平面及中央组淋巴结清扫边界等方面介绍腹腔镜右半结肠CME手术的相关内容及注意事项。     

Laparoscopic right hemicolectomy with complete mesocolic excision

Background

Complete mesocolic excision (CME) has recently been reemphasized as a technical approach for anatomical dissection during colon cancer surgery. Although a laparoscopic approach for right colon cancer is performed frequently, identifying an adequate dissection plane is not always easy. In our practice, the patient lies in a modified lithotomy position. The first step is ileocolic area mobilization, followed by adequate retraction of the cecum laterally. This procedure enables discrimination of the ileocolic vessels and superior mesenteric vessels. Importantly, this method facilitates identification of the superior mesenteric vein (SMV), followed by the identification of the root of ileocolic pedicles. After that, sharp dissection along the SMV in an upward direction helps to safely identify the middle colic artery (MCA). Dissection then continues to the level of the origin of MCA, after which the right branch of MCA can be divided.

Methods

A total of 128 consecutive patients (63 males) who underwent laparoscopic CME for right colon cancer by a single surgeon were analyzed in this study.

Results

There was no conversion to open surgery. The median operation time was 192 min (interquartile range [IQR] 118–363 min). The median proximal and distal resection margins were 11 and 10 cm, respectively. The median number of harvested lymph nodes was 28 (IQR 3–88). There were six postoperative complications (4.6 %). The median hospital stay was 5 days (IQR 4–37 days). The video demonstrates a laparoscopic CME for a patient who had advanced distal ascending colon cancer.

Conclusion

In conclusion, identifying the anatomical location of the SMV and performing meticulous dissection along the SMV is an essential procedure for containing all potential routes of metastatic tumors. Initial ileocecal mobilization with adequate counter traction of the cecum may be useful for novice surgeons attempting to identify the location of SMV during laparoscopic CME for right colon cancer.     

腹腔镜右半结肠癌CME手术技巧

当腹腔镜结直肠手术普及的同时,完整全结肠系膜切除(CME)理念也逐渐成为右半结肠癌根治手术的标准。腔镜下完成CME手术涉及较为复杂的解剖结构,中央淋巴结的清扫可能带来潜在的风险,规范手术步骤、熟悉血管解剖,可以缩短学习曲线,减少并发症的发生。从解剖位置恒定的回结肠血管开始,完成肠系膜上静脉的裸化,直至完整游离右半结肠系膜,是目前国内外广泛采用的手术步骤。精细解剖可以减少出血,防止手术野的模糊,清晰分辨解剖层次,可以顺利完成手术过程。     

腹腔镜全结肠系膜切除术

In the latest 50 years,the radical dissection rate of colonic cancer and the 5-year survival rate have been improved as colonic surgery techniques improve.In 1991,Jacob performed the first laparoscopic...     

Laparoscopic complete mesocolic excision with central vascular ligation in right colon cancer:A comprehensive review

Aim of the study is to comprehensively review the latest trends in laparoscopic complete mesocolic excision(CME) with central vascular ligation(CVL) for the multimodal management of right colon cancer. Historical and up-to-date anatomo-embryological concepts are analyzed in detail,focusing on the latest studies of the mesenteric organ,its dissection by mesofascial and retrofascial cleavage planes,and questioning the need for a new terminology in colonic resections. The rationale behind Laparoscopic CME with CVL is thoroughly investigated and explained. Attention is paid to the current surgical techniques and the quality of the surgical specimen,yielded through mesocolic,intramesocolic and muscularis propria plane of surgery. We evaluate the impact on long term oncologic outcome in terms of local recurrence,overall and disease-free survival,according to the plane of resection achieved. Conclusions are drawn on the basis of the available evidence,which suggests a pivotal role of laparoscopic CME with CVL in the multimodal management of right sided colonic cancer: performed in the right mesocolic plane of resection,laparoscopic CME with CVL demonstrates better oncologic results when compared to standard non-mesocolic planes of surgery,with all the advantages of laparoscopic techniques,both in faster recovery and better immunological response. The importance of minimally invasive mesoresectional surgery is thus stressed and highlighted as the new frontier for a modern laparoscopic total right mesocolectomy.     

完整结肠系膜切除治疗结肠癌初步分析

目的:探讨完整结肠系膜切除(CME)在结肠癌手术治疗中的应用.方法:回顾性分析2009年12月-2012年6月行CME和中央血管高位结扎(CVL)的34例结肠癌患者临床资料.结果:患者术后UICC病理分期:Ⅰ期4例,Ⅱ期14例,Ⅲ期16例.中位淋巴结清扫数18枚,Ⅲ期患者中18.8％ (3/16)的系膜根部淋巴结转移阳性.全组无围术期死亡,无术中副损伤.手术时间2.5～3.5(中位数2.75)h,术中出血量80～200(中位数110)mL,术后排气时间3～5(中位数4)d,排便时间4～6(中位数5)d,术后住院时间11～20(中位数14)d.术后并发症包括切口感染3例,肺部感染1例,乳糜漏1例,无吻合口瘘发生,近期无肠梗阻发生.34例患者获6个月至2年的随访,未发现局部复发;1例术后16个月发现肝转移,3个月后死亡.结论:结肠癌患者行CME联合CVL安全、可行,短期效果良好,CME联合CVL有可能成为一种标准化的结肠癌手术术式.