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目的:探讨后腹腔镜下肾癌根治术中肾静脉及属支损伤的处理对策及预防方法。方法:回顾性分析收治238例后腹腔镜下行肾癌根治术视频,总结术中肾静脉及属支损伤的原因及处理措施。手术均采用同样步骤处理肾血管,剔除腹膜外脂肪,纵行切开Gerota筋膜,以腰大肌为背侧标志游离肾脏背侧,于肾脏中部逐渐分离暴露肾动静脉,Hemo-lok及钛夹处理肾血管。结果:238例患者术中发生肾静脉及属支损伤12例,其中肾静脉损伤7例,生殖静脉2例,腰静脉2例,肾上腺中央静脉1例。9例患者术中于第3个Trocar近腋中线方向旁开2横指处增加第4个Trocar。所有患者术中发生出血后即予增加腹压(15 mm Hg),纱布压迫,尽量吸净出血,获得相对清晰视野明确出血部位后进行下一步处理。1例患者为肾静脉离断后近端钛夹脱落,出血明显,视野不清改开放手术;1例生殖静脉撕裂出血采用纱布压迫止血后,近心端用可吸收线缝扎止血;2例肾静脉近端撕裂出血采用血管缝线8字缝合止血;其余8例均采用钛夹及Hem-o-lok钳夹止血,肾脏切除后减少气腹压力,再次检查出血区域,未见明显出血。结论:肾静脉及属支损伤的主要原因是术前对肾血管分支及走向误判、术野暴露欠佳、操作粗暴等。术中冷静处理,综合采用增加Trocar、调整气腹压力、压迫、钳夹、缝合等方法多可处理。术前完善影像学检查并充分评估预判、良好暴露以及寻找解剖标志可有效预防肾静脉及其属支损伤。
Objective: To investigate the treatment and prevention of renal vein and its branches injury under retroperitoneal laparoscopic radical nephrectomy. Methods: The retrospective analysis of 238 cases of retroperitoneal laparoscopic radical nephrectomy video, summarize the reasons and treatment of renal vein injury and treatment. The same procedures were used for the treatment of renal blood vessels, removing extraperitoneal fat, longitudinal cutting Gerota fascia, the psoas to the dorsal side of the free kidney dorsal, in the middle of the kidney gradually exposed the renal artery and vein, Hemo-lok and titanium Treatment of renal vessels clip. Results: There were 12 cases of renal vein and genu branch injury in 238 cases, including 7 cases of renal vein injury, 2 cases of reproductive vein, 2 cases of lumbar vein and 1 case of central adrenal vein. In the 9 patients, the fourth Trocar was added in the direction of the third axillary midline near the second Trocar. All patients with intraoperative bleeding immediately after the increase in abdominal pressure (15 mm Hg), gauze oppression, aspiration net bleeding, a relatively clear vision of the site of bleeding after the next step. One patient had a proximal titanium clip detachment after renal vein disconnection, obvious hemorrhage, unclear vision, and open surgery. One patient with hemorrhage of reproductive veins was treated with gauze to stop bleeding, and the proximal end was sutured with absorbable suture to stop bleeding. Two patients Renal vein proximal tearing hemorrhage suture with blood suture 8 words suture hemostasis; the remaining 8 cases were used titanium clip and Hem-o-lok clamp to stop bleeding, reduce the pneumoperitoneum pressure after renal resection, re-examination of the bleeding area, no significant bleeding . Conclusion: The main reason of renal vein and genu branch injury is preoperative misjudgment of renal vessel branch and operation, poor surgical field exposure, crude operation and so on. Intraoperative cool treatment, the comprehensive use of increased Trocar, pneumoperitoneum pressure adjustment, oppression, jaws, suture and other methods can handle. Preoperative imaging and improve the prognosis of adequate assessment, good exposure and looking for anatomical landmarks can be an effective prevention of renal vein injury and its branches.