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目的:复习后腹腔镜下肾及肾上腺关系的应用解剖,探讨后腹腔镜肾癌根治术中保留肾上腺的处置策略。方法:2009年6月至2012年4月收治105例局限性肾癌患者,其中左侧48例,右侧57例;肿瘤最大径1.5～7.5 cm,平均4.3 cm。均根据以下策略保留肾上腺:(1)经后腹腔途径处理肾蒂血管后,于肾门区域内侧、肾上腺下方游离至肾前筋膜内侧,抬高肾上极,使其具有一定张力,于肾脏后上方游离肾上腺底部,至肾上极内上方,使两者分离;(2)进一步向肾脏上极内侧游离至肾前筋膜内侧,使肾上腺与肾周脂肪完全脱离。结果:105例手术均获成功,无一例中转开放手术。手术时间31～80 min,平均43 min;出血量10～150 ml,平均30 ml;术后3～7 d出院。术中3例发生肾上腺外侧支稍撕裂。结论:根据后腹腔镜下肾及肾上腺的解剖特点,此处置策略使手术操作更加直接,暴露良好,受肾上极弧度及肾周脂肪干扰小;分离肾上腺后稍加推进,即可使肾上腺与肾周脂肪完全脱离,使肾上极的游离更加简便、省时,撕裂肾上腺的几率降低。
Objective: To review the anatomy of the relationship between laparoscopic renal and adrenal gland, and to discuss the treatment strategy of retained adrenal gland in laparoscopic radical nephrectomy. METHODS: From June 2009 to April 2012, 105 patients with localized renal cell carcinoma were treated, including 48 on the left and 57 on the right. The largest diameter of the tumor was 1.5-7.5 cm (average 4.3 cm). The adrenal glands were preserved according to the following strategies: (1) After the retroperitoneal approach to treat the pedicle of the renal pedicle, the medial part of the renal hilum was free from the area below the adrenal glands to the medial side of the anterior fascia, elevating the upper pole of the kidney to make it have a certain tension, After the top of the free adrenal glands to the top of the kidney pole, so that the two separated; (2) further to the inner pole of the kidney free to the inside of the anterior fascia, the adrenal and perirenal fat completely separated. Results: All of the 105 surgeries were successful, and none of them underwent open surgery. The operation time ranged from 31 to 80 minutes with an average of 43 minutes. The amount of bleeding was from 10 to 150 ml with an average of 30 ml. The patients were discharged from 3 to 7 days after operation. 3 cases of surgery occurred in the adductor lateral branch slightly tear. Conclusion: According to the anatomic characteristics of retroperitoneal laparoscopic kidney and adrenal gland, this treatment strategy makes the operation more direct and well exposed, and it is less affected by arcuate arrhythmia and perirenal adiposity. After the adrenal gland is slightly separated, the adrenal gland Perirenal fat completely detached, so that the upper pole of the kidney is more simple and convenient, save time and reduce the risk of tearing the adrenal gland.