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中华腔镜外科杂志(电子版) ›› 2022, Vol. 15 ›› Issue (03): 148 -151. doi: 10.3877/cma.j.issn.1674-6899.2022.03.006

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郑氏经脐单孔腹膜外路径淋巴结切除的探索
王卡娜1, 郑莹1,(), 陈思敬1, 杨帆1, 彭诗意1, 王乔1, 周小驰1   
  1. 1. 610041 成都,四川大学华西第二医院妇产科,出生缺陷与相关妇儿疾病教育部重点实验室
  • 收稿日期:2022-05-12 出版日期:2022-06-30
  • 通信作者: 郑莹
  • 基金资助:
    四川省科技厅重点研发项目(2020YFS0049); 成都市科技局技术创新研发项目(2019-YF05-00473-SN)

Exploration of Zheng′s transumbilical laparoendoscopic single­site extraperitoneal approach for lymphadenectomy

Kana Wang1, Ying Zheng1(), Sijing Chen1   

  • Received:2022-05-12 Published:2022-06-30
  • Corresponding author: Ying Zheng

盆腔和腹主动脉旁淋巴结切除是妇科恶性肿瘤手术的重要组成部分。腹腔镜下淋巴结切除术具有直视放大手术视野的效果,与开腹手术相比,具有精准、微创、出血少、并发症少、术后恢复快等优点,但血管区域的显露,尤其是高位腹主动脉旁(肾静脉水平)淋巴结的充分显露,对于妇科肿瘤医师较为困难。腹腔镜下经腹膜外路径,可完美地解决腹主动脉旁淋巴结显露,尤其对于在常规腹膜内路径下显露极为困难的肥胖患者,腹膜外路径可规避肠道等内脏器官的干扰,清扫范围可轻松达左肾静脉水平。然而,传统的多孔腹腔镜只能经侧入路进入腹膜后间隙,该入路虽较好地解决了腹主动脉旁淋巴结显露及清扫问题,但因侧入路受角度的影响,盆腔视野却又受到限制,无法显露盆腔淋巴结切除范围,尤其是对侧闭孔区域,这又让原本在常规腹膜内路径下能轻松完成的盆腔淋巴结显露和清扫成为困难。

图1 后腹膜路径入口的选择与腹膜悬吊线提拉
图2 荷包缝合以加固后腹膜注:A~C.在腹膜牵拉悬吊线周围缝合一圈
图3 腹膜后气腔的建立及后腹膜置入单孔腹腔镜切口保护套注:A. 在荷包缝合线中间插入气腹针,注入二氧化碳气体,分离腹膜后间隙;B. 剪断悬吊缝线,在腹膜后开窗,形成一个约2 cm的小切口,建立后腹膜手术切入口;C. 插入单孔入路平台的切口保护套后,可以清楚地看到腹主动脉分叉,腹膜后间隙的初步建立;D. 将单孔入路平台安装在切口保护套上,充气形成腹膜后气腔
图4 经脐单孔腹膜外入路建立示意(引自:Chen S, Zhou J, Zheng Y, et al. Para-aortic and right obturator lymphadenectomy for surgical staging of advanced cervical cancer through the tu-less extraperitoneal approach[J]. J Minim Invasive Gynecol,2021, 28(6): 1140.)
图5 腹膜后间隙的显露(盆腔)注:A.Ⅰ.左髂外动脉;Ⅱ.左髂外静脉;Ⅲ.左闭孔神经;B.Ⅳ.右闭孔神经;Ⅴ.右髂外静脉;Ⅵ.右髂外动脉;C.Ⅶ.左髂总动脉;Ⅷ.左髂总静脉;Ⅸ.右髂总动脉;Ⅹ.右髂总静脉
图6 腹膜后间隙的暴露(腹主动脉旁淋巴结)注:A. 1.下腔静脉;2.肾静脉;3.腹主动脉;B. 4.肠系膜下动脉;C. 5.腹主动脉;6.右髂总动脉;7.左髂总动脉;D. 8.下腔静脉;9.锥静脉;10.腹主动脉
表1 单孔腹腔镜腹膜外路径淋巴结切除术淋巴结获取情况(枚)
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