腹腔镜联合纵隔镜在食管癌根治术中的应用

作者：秦雄,徐志飞,仇明,吴彬,钟镭,李建秋,郑向民,江道振。

【摘要】 目的：探讨腹腔镜联合纵隔镜在食管癌根治术中的应用价值。方法：运用超声刀和LigaSure行腹腔镜下游离胃术、腹腔镜联合纵隔镜经后纵隔食管癌切除、胃食管左颈吻合8例,其中食管中段癌3例、食管下段癌5例,ＴＮM分期为T１～3N０～１M０。结果：全组无手术死亡,无中转开胸或开腹手术,术中无输血,手术时间180～220min,平均200min,术中出血量50～150ml,平均l００ml,纵隔淋巴结清扫０～8枚,平均3.2枚,腹部淋巴结清扫0～6枚,平均1.4枚,术后胃肠功能恢复时间3～4d,平均3.7d,术后住院时间10～19d,平均12d。结论：对于中下段无外侵(≤T3)的食管癌患者在腹腔镜联合纵隔镜下行食管癌根治术可以提高手术的安全性,缩短手术时间,减少术中出血,减轻手术创伤,具有良好的推广应用价值。

【关键词】 食管癌;超声刀；LigaSure；腹腔镜；纵隔镜。

Application of esophagectomy via laparoscopy combined mediastinoscopy。

【Abstract】 Ｏbjective:To explore thc value of esophagectomy via laparoscopy combined mediastinoscopy.Methods:Esophagectomy were performed by gastric mobilization,dissection of esophageal carcinoma via laparoscopy and left cervicotomy via mediastinoscopy by using the ultrasonically activated scalpel and ligasure vessel sealer,involving 8 patients with esophageal carcinoma (3 in middle segment,5 in lower segment).The TNM staging was T１～3N０～１M０.Results:All the operations were successful without blood transfusion.No perioperation mortality was observed and no conversion to open surgery was required.The operative time was 180220min(mean 200min),the blood loss was 50150ml(mean 100ml),the number of removed mediastinal lymph nodes was 08(mean 3.2),the number of removed paraleft gastric arterial lymph nodes by laparoscopic surgery was 06(mean l.4).The recovery time of gastrointestinal function was 34 days(mean 3.7 days).The hospitalization was 1019 days(mean 12days).Conclusions:So long as the operative indication is strictly determinated with middle and lower esophageal carcinoma without invasion(≤T3),esophagectomy via laparoscopy combined mediastinoscopy by using the ultrasonically activated scalpel and ligasure vessel sealer can improve the operative safety,shorter operative time,reduce blood loss and lessen tissue injury.

【Key words】 Esophageal carcinoma;Ultrasonically activated scalpel;LigaSure vessel sealer;Laparoscopy;Mediastinoscopy。

为了减少食管癌围手术期并发症的发生率,微创外科技术越来越多地应用于食管癌手术中［１］。腔镜食管癌手术因微创,出血少、疼痛轻、术后并发症少、住院时间短等优点,愈来愈被大家认可［25］。超声刀和LigaSure作为新型的微创手术器械目前正逐渐应用于临床外科。我院自2004年4月至2005年6月运用超声刀和LigaSure为8例食管癌患者施行腹腔镜下胃游离术、腹腔镜联合纵隔镜经后纵隔食管癌切除、胃食管左颈吻合重建消化道,取得良好的手术效果,现报道如下。

1 资料与方法。

11 临床资料 全组8例中男6例,女2例,42～75岁,平均64.5岁,既往均无胸腹部手术史,术前均经上消化道钡餐及纤维内镜下活检病理检查,明确食管癌诊断并检查确定胃的可用性,同时行肺功能、腹部B超、心电图及肝肾功能、血常规检查、食管腔内为超声检查,所有患者均未发现手术禁忌。食管中段癌3例,食管下段癌5例,食管癌长度2～5cm,平均3.8cm,术前ＴＮＭ分期为T１～3N０～１M０,术后行持续心电监护、血氧饱和度监测。

1.2 手术方法 均采用气管插管全身麻醉。患者平卧“Nissen”术体位,维持气腹压力12mm Hg左右,选脐孔切口置入30°腹腔镜,探查腹腔无明显粘连,腹腔脏器无异常后,选左、右肋弓下及脐上5cm左、右腹直肌旁为操作孔。于大网膜无血管区用5mm超声刀切开大网膜囊,沿胃网膜血管弓外侧分离胃大弯侧网膜组织,右至十二指肠球部,保留胃网膜右动脉及其血管弓；向左游离并切断胃网膜左动脉、胃短动脉；切开小网膜囊,游离胃左动、静脉,同时游离胃左动脉旁淋巴结,在胃左血管根部用LigaSure切断胃左动、静脉;切开贲门部腹膜返折,分离腹段食管,胃游离后,超声刀沿小弯侧将网膜、胃左动脉及胃左动脉旁淋巴结一并同时剔除。腹腔镜下经纵隔游离中下段食管,超声刀切断脑肌脚,放射状切开并扩大食管膈肌裂孔,游离腹段食管后,腹段食管套带结扎,向腹部牵引,腹腔镜经扩大的膈肌裂孔进入纵隔,钝性推移食管周围疏松结缔组织,遇食管滋养血管后超声刀离断,逐渐向食管近端游离,最高游离高度可达气管隆突下,同时清扫食管床可见淋巴结。纵隔镜下游离上段食管,在胸锁乳突肌内侧缘作左颈部纵切口,长约5cm,常规游离颈段食管,套带向外牵引,手指作胸廓入口处食管钝性分离,置入纵隔镜,钝性分离食管周围疏松组织,遇食管固有动脉用超声刀离断,逐渐向食管远端游离,游离至气管隆突水平和腹腔镜下游离的下段食管会合,同时游离清扫食管旁淋巴结,术中注意喉返神经的保护。腹腔镜下用直线切割缝合器切断贲门,游离食管由左颈部拉出,食管拔脱器由左颈部经纵隔置入腹腔,胃底部最高点腹腔镜下缝合牵引线并结扎固定于拔脱器头上,缓慢牵引由左颈部切口拉出,胃食管左颈部行端侧吻合。