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中华腔镜外科杂志(电子版)

中华腔镜外科杂志(电子版) ›› 2022, Vol. 15 ›› Issue (06): 341 -346. doi: 10.3877/cma.j.issn.1674-6899.2022.06.005

论著

免器械手工吻合技术在完全腹腔镜左半结肠切除术中的应用
王举1,†(), 高小平1, 张凤联1, 姜世洲1, 王永强1, 姜洪伟1   
  1. 1. 010017　呼和浩特，内蒙古自治区人民医院胃肠外科
  • 收稿日期:2022-10-25 出版日期:2022-12-30
  • 通信作者: 王举
  • 基金资助:
    内蒙古自治区自然科学基金项目(2022MS08062)

The application of the staple-free hand-sewn anastomosis on the totally laparoscopic left hemicolectomy

Ju Wang1,†(), Xiaoping Gao1, Fenglian Zhang1, Shizhou Jiang1, Yongqiang Wang1, Hongwei Jiang1   

  1. 1. Department of Gastrointestinal Surgery, Inner Mongolia Hospital, Hohhot 010017, China
  • Received:2022-10-25 Published:2022-12-30
  • Corresponding author: Ju Wang
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目的

探讨免器械手工吻合技术在完全腹腔镜左半结肠切除术(totally laparoscopic left colectomy, TLLC)中的安全性和可行性。

方法

采用回顾性队列研究方法，回顾分析内蒙古自治区人民医院胃肠外科2020年4月至2022年4月应用免器械手工吻合技术TLLC、应用吻合器完全或辅助腹腔镜左半结肠切除消化道重建的病例资料。符合入组标准的左半结肠癌患者共77例，根据消化道重建方式分为完全腹腔镜免器械手工吻合组(35例)、器械吻合组(Overlap、端对端吻合，42例)两组。统计分析腹腔镜下两种消化道重建方式患者的手术时间、吻合口并发症、腹腔感染、术后恢复情况等资料。

结果

两组性别、年龄、体质量指数、ASA分级、肿瘤部位、TNM分期、术前合并糖尿病和结肠不全梗阻等均差异无统计学意义(P>0.05)。两组均行R0切除，无中转开腹手术。腹腔镜下免器械手工吻合组与器械吻合组在消化道重建时间、辅助切口方面差异有统计学意义，免器械手工吻合组重建时间长于器械吻合组[(33.7±5.0)min比(27.1±4.9)min, P<0.001]，辅助切口长度短于器械吻合组[(5.6±0.84)cm比(7.7±1.11)cm, P<0.001]。两组总体并发症发生率、吻合口出血、吻合口漏、吻合口狭窄、腹腔感染并发症发生率均差异无统计学意义(P>0.05)；术后首次肛门排气时间和住院时间均差异无统计学意义(P>0.05)。两组并发症均经非手术治疗痊愈，无非计划手术和死亡病例。

结论

免器械手工吻合技术在完全腹腔镜左半结肠切除消化道重建中简便、安全、可行，可作为器械吻合的补充，但需经验丰富的腹腔镜外科医师实施。

关键词: 手工缝合技术, 左半结肠切除术, 完全腹腔镜手术, 消化道重建
Objective

To explore the safety and feasibly of staple-free hand-sewn laparoscopic colonic anastomosis in the totally laparoscopic left hemicolectomy.

Methods

From Apr. 2020 to Apr. 2022, in the Department of Gastrointestinal Surgery, Inner Mongolia Autonomous Region People's Hospital, patients who underwent total laparoscopic left colectomy with staple-free hand-sewn and total laparoscopic or laparoscopic-assisted left colectomy with stapler were retrospectively analyzed. According to the method of digestive reconstruction , a total of 77 patients with left colon cancer who met the inclusion criteria were divided into two groups: staple-free hand-sewn laparoscopic colonic anastomosis group (35 cases) and staple anastomosis (Overlap, end-to-end anastomosis) group (42 cases). The operation time, anastomotic complications, abdominal infection and postoperative recovery of the two types of digestive reconstruction were statistically analyzed.

Results

No significant differences were founded in gender, age, BMI, ASA grade, tumor location, TNM stage, preoperative diabetes mellitus and preoperative imcomplete colon obstruction between the two groups (P>0.05). R0 resection was performed in both groups, none required conversion to open surgery. Moreover, there were statistically significant differences in digestive reconstruction time and auxiliary incision between the two groups.The reconstruction time of staple-free hand-sewn group was remarkably longer than staple anastomosis group[(33.7±5.0)min vs(27.1±4.9)min, P<0.001], The length of auxiliary incision of staple-free hand-sewn group was shorter than that of staple anastomosis group[(5.6±0.84)cm vs(7.7±1.11)cm, P<0.001]. In addition, there were no statistically significant differences in the incidence of overall complications, anastomotic bleeding, anastomotic leakage, anastomotic stenosis, and abdominal infection between the two groups(P>0.05). There was also no significant difference in the first flatus time and hospital stay(P>0.05). The complications of the two groups were cured by non-operative treatment. No reoperation and death cases occurred.

Conclusions

The technique of staple-free hand-sewn anastomosis is simple, safe and feasible in total laparoscopic left colectomy , it can be used as a supplement to staple anastomosis, but it needs to be performed by experienced laparoscopic surgeons.

Key words: Laparoscopic, Left colectomy, Hand-sewn technique, Digestive system reconstruction
表1 两组左半结肠癌患者基线资料比较
基线资料 免器械手工吻合组(35例) 器械吻合组(42例) P值
年龄(岁，±s) 61.46±12.9 64.74±10.9 0.230
性别[例(%)]     0.329
  男 19(54.3) 26(61.9)  
  女 16(45.7) 16(38.1)  
体质量指数(kg/m2, ±s) 23.34±4.5 22.69±3.6 0.485
ASA分级[例(%)]     0.368
  Ⅰ级 18(51.4) 24(57.1)  
  Ⅱ级 12(34.3) 13(31.0)  
  Ⅲ级 5(14.3) 5(11.9)  
位置[例(%)]     0.552
  横结肠脾区 5(14.3) 6(14.3)  
  降结肠脾区 9(25.7) 11(26.2)  
  降结肠 21(60.0) 25(59.5)  
术前主要合并症[例(%)]      
  不完全梗阻 4(11.4) 4(9.5) 0.537
  糖尿病 5(14.3) 7(16.7) 0.514
TNM分期[例(%)]     0.402
  Ⅰ期 5(14.3) 5(11.9)  
  Ⅱ期 11(31.4) 9(21.4)  
  Ⅲ期 10(28.6) 20(47.6)  
  Ⅳ期 9(25.7) 8(19.1)  
图1 腹腔镜左半结肠切除术注：A.距离肿瘤远端和近端各10 cm用Echelon 60A切断横结肠和乙状结肠；B.用Covidien Vlocl 3-0倒刺线行结肠断端后壁全层连续内翻缝；C.用Covidien Vlocl 3-0倒刺线行结肠断端前壁全层连续水平褥式内翻缝合；D.用Covidien Vlocl 3-0倒刺线行结肠吻合口浆肌层连续包埋缝合加固；E.左半结肠标本；F.耻骨上横切口取标本；G.从原阑尾切口取标本
表2 两组左半结肠癌患者术后观察指标比较
项目 免器械手工吻合组(35例) 器械吻合组(42例) 统计量 P值
吻合时间(min，±s) 33.7±5.0 27.1±4.9 H＝23.824 <0.001
并发症[例(%)] 7(20.0) 9(21.4) F＝0.024 0.878
  吻合口出血 1(2.9) 5(11.9) F＝1.098 0.295
  吻合口漏 3(8.6) 2(4.8) F＝0.045 0.883
  吻合口狭窄 0(0.0) 0(0.0)    
  腹腔感染 3(8.6) 2(4.8) F＝0.045 0.883
辅助切口长度(cm，±s) 5.6±0.84 7.7±1.11 H＝26.793 <0.001
首次肛门排气时间(d，±s) 3.7±1.0 3.8±1.2 H＝0.360 0.903
住院时间(d，±s) 11.9±3.9 12.5±3.2 H＝0.190 0.663
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