探讨单孔胸腔镜手术复杂袖式肺切除的手术技术和临床效果。

同济大学附属上海市肺科医院胸外科2016年至2019年共完成单孔胸腔镜袖式肺切除术(不包括楔形成形术和单纯血管成形术)167例，其中主要是上叶和下叶袖式肺切除术共141例；分析比较少见且难度更大的单孔胸腔镜袖式肺切除术26例，统称为"复杂袖式肺切除术"。纳入标准：超出一叶的袖式肺切除(两叶袖式肺切除或肺叶＋肺段袖式肺切除)，累及隆突的袖式肺切除，肺段的袖式肺切除，右中叶袖式肺切除。排除标准：胸腔镜辅助和开胸袖式肺叶切除，支气管成形肺叶切除，单孔胸腔镜下常规肺叶(上叶和下叶)袖式肺切除术。纳入患者：右肺上中叶或中下叶袖式肺切除7例，左下叶＋舌段袖式肺切除6例，累及隆突的袖式肺切除6例(其中袖式右肺上叶＋隆突切除重建2例、袖式全肺切除1例、右主支气管节段切除＋双隆突重建1例、袖式左肺上叶切除＋隆突重建1例、袖式右肺中下叶切除＋隆突成形1例)，肺段的袖式切除4例(固有段切除2例、舌段切除2例)，右中叶袖式肺切除3例。

本组患者术后病理分别是肺鳞状细胞癌15例、错构瘤4例、肺腺癌3例、腺样囊性癌1例、类癌1例、恶性淋巴瘤1例、淋巴结外窦组织细胞增生症1例。术中出血量50～1 000 ml，平均出血量(169±205.94)ml；平均手术时间(190.3±72.6)min，四分位间距150～232.5 min；术中清扫淋巴结站(5.86±0.99)站，均包含隆突下淋巴结；清扫淋巴结数目6～29枚，平均(14.04±5.41)枚；手术日引流量(265.41±173.98)ml，总住院时间(10.38±4.87)d，术后住院时间(4.96±1.90)d。恶性肿瘤中16例(16/19)接受术后化疗。长期随访：术后1例失访；2例术后余肺肿瘤复发、1例吻合口狭窄、1例术后进行放(化)疗后出现支气管食管瘘、1例术后乳糜胸。术后随访时间(15.6±10.7)个月。患者无围手术期死亡；至今，1例术后1年广泛转移死亡，其他患者均存活。

单孔胸腔镜下完成复杂袖式肺切除是胸部微创技术的有益探索和重要进步，选择合适病例且熟练掌握胸腔镜技术的前提下可以使患者获得更佳的疗效。

To explore the feasibility of uniportal VATS complex sleeve lung resection and summarize the surgical techniques and clinical outcomes.

From 2016 to 2019, a total of 167 cases of uniportal thoracoscopic sleeve lung resection were perfomed by one surgical team in Shanghai Pulmonary Hospital. Among them, there are a total of 141 cases of the upper or lower lobe sleeve resections, already analyzed in previous articles.This article aims to analyze the remaining 26 technique-demanding cases. We categorize these operations as "complex sleeve lung resection" . Inclusion criteria are as follows, sleeve lung resection of more than one lobe (bilobar sleeve resection or lobe + segment sleeve resection), sleeve lung resection involving the carina, sleeve segmental resection, right middle sleeve lobectomy. Exclusion criteria includes sleeve lobectomy through thoracotomy, wedge bronchoplasty, upper or lower sleeve lobectomy. The recruited cases are 7 right upper-middle or middle-lower sleeve bilobectomy, 6 left lower lobe + lingular segment sleeve resection, 6 sleeve carinal resection, 4 sleeve segmentectomy, 3 right middle sleeve lobectomy.

There were 15 cases of lung squamous cell carcinoma, 3 cases of lung adenocarcinoma, 4 cases of hamartoma, 1 case of adenoid cystic carcinoma, 1 case of carcinoid tumor, 1 case of malignant lymphoma, and 1 case of extranodal sinus histiocytosis. The average blood loss during the operation was (169 ± 205.94) ml, 50-1 000 ml. The average operation time was (190.3±72.6) min, with interquartile range 150-232.5 min. The average lymph node stations removed were (5.86±0.99), including station7 in all cases. The number of lymph nodes was 6-29, with an average of (14.04 ± 5.41). On operation day, the drainage volume was (265.41 ± 173.98 )ml. The total hospital stay was (10.38 ± 4.87) d, and postoperative hospital stay was (4.96 ± 1.90) d. Sixteen patients with malignant tumors received postoperative chemotherapy (16/19). One case was lost to long-term follow-up. Anastomotic complications occurred in 1cases. Tumor recurrence occurred in 2 case. Bronchoesophageal fistula occurred in 1 patient after radiochemotherapy. One case suffered postoperative chylothorax recovered after reoperation. The postoperative follow-up time was( 15.6 ± 10.7 )months. No perioperative death occurred. Until now, one patient died of distal metastasis 1 year after operation, and other patients still survive.

Uniportal VATS sleeve complex lung resection could be completed with an improvement of minimally invasive surgical techniques, and be beneficial for certain selective patients.