腹腔镜治疗肾囊肿的临床研究
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摘要
目的:探讨腹腔镜肾囊肿去顶减压术的方法和临床应用价值,比较腹腔镜肾囊肿去顶减压术较开放性去顶减压术的疗效和优点。
方法:回顾性分析128例(144侧)采用经腹腔入路及腹膜后入路腹腔镜行肾囊肿去顶减压术的适应征,围手术期准备,手术入路途径,术后并发症的原因、防治,如何保证手术成功等。128例均在全麻下实施手术,其中经腹腔途径115例,腹膜后途径13例,并与86例开放性肾囊肿去顶术患者进行比较,对两组术式的临床疗效、手术时间、术中失血量和术后疼痛程度及住院天数等指标进行对比研究。
结果:腹腔镜组术前70例有不同程度患侧腰部疼痛,术后腰痛消失者72.9%(51/70),腰痛好转者21.4%(15/70);开放手术组术前52例有不同程度患侧腰部疼痛,术后腰痛消失者71.2%(37/52),,腰痛好转者21.6%(11/52);两组比较差别无显著性意义(P>0.05),术后两组均无复发。腹腔镜组术后均未注射止痛剂,平均发热2.1d,术后平均住院日3.62±1.53d,伤口疼痛麻木持续2个月;开放手术组术后37.2%(32/86)注射止痛剂,平均发热3.2d,术后平均住院日9.72±2.15d,伤口疼痛麻木持续9个月,两组间比较差别均有显著性意义(P<0.05)。术后并发症发生率腹腔镜组为1.6%(2/128),主要为手术区积液及出血等;开放手术组为8.1%(7/86),主要为切口感染、肺部感染等。术后病理除1例为肾癌外,其余均符合单纯性肾囊肿的诊断。全部病例随访1～24个月,均未见复发。
结论:腹腔镜肾囊肿去顶减压术治疗肾囊肿,疗效可靠,具有创伤小,痛苦少,术后康复快,并发症少,明显优于开放性手术。具有较高的实用价值,可以完全替代传统的开放性手术,但应做好充分的术前准备,根据术者的习惯选择正确的手术入路途径。
Objective To evaluate the methods and clinical value of laparoscopic renal cyst decortication. To compare the therapeutic effects and advantages of laparoscopic versus open renal cyst unroofing.Methods The 128 cases treated with laparoscopic renal cyst decortication were reviewed retrospectively in the fields of indications to operation, preoperative preparation, approaches, postoperative complications and how to accomplish operation. 128cases were treated by laparoscopic operation with the general anesthesia. 115 cases in transperitoneal and 21 cases in retroperitoneal .All the cases were compared with 86 cases treated by open renal cyst decortication.Then the clinical advantages ,operation time ,blood loss,the durations of hospitalization after operation,etc were studied.Result 70 cases have pains in the back .After opretion the pain of the back resolved in 72.9%(51/70)and improved in 21.4%(15/70) in the laparoscopic group,and in the open surgical group71.2%(37/52) and 21.6%(11/52) (P>0.05).There was no recurrence in both groups. Mean hospitalizations day was 3.62±1.53 days in the laparoscopy group, whereas it was 9.72 ± 2.15 days in the open surgical group. Post operative fever last day mean of 2.1 and 3.2 days in the two groups respectively (P<0.05). There was no need of analgesia afte rlaparoscopy while 37.2%(32/86) of the patients needed analgesia injection after open surgery(P<0.05). Incisional pain or numbness lasted a mean of 2 months in the laparoscopy group and with a mean of 9
months in the open surgery group. The incidence of complication was 1.6%(2/128) in the laparoscopic group being mainly perirenal hematoma and hemorrhage in the operative field. In the open surgery group the complications were infection of incisional wound and infection of lung with amorbidity of 8.1%(7/86). 128 cases were followed up froml to 24 months after surgery. All cases were satisfied with the clinical effect and no obvious complications were found.Conclusion The laparoscopic renal cyst decortication has more advantages of less trauma,quicker recovery,less suffering and complications than open renal cyst decortication and has more practical values, it may take place of open renal cyst decortication. Sufficient preoperative preparations are indispensable to all cases and the approaches must be selected correctly in the light of the habit of operators.
方法:回顾性分析128例(144侧)采用经腹腔入路及腹膜后入路腹腔镜行肾囊肿去顶减压术的适应征,围手术期准备,手术入路途径,术后并发症的原因、防治,如何保证手术成功等。128例均在全麻下实施手术,其中经腹腔途径115例,腹膜后途径13例,并与86例开放性肾囊肿去顶术患者进行比较,对两组术式的临床疗效、手术时间、术中失血量和术后疼痛程度及住院天数等指标进行对比研究。
结果:腹腔镜组术前70例有不同程度患侧腰部疼痛,术后腰痛消失者72.9%(51/70),腰痛好转者21.4%(15/70);开放手术组术前52例有不同程度患侧腰部疼痛,术后腰痛消失者71.2%(37/52),,腰痛好转者21.6%(11/52);两组比较差别无显著性意义(P>0.05),术后两组均无复发。腹腔镜组术后均未注射止痛剂,平均发热2.1d,术后平均住院日3.62±1.53d,伤口疼痛麻木持续2个月;开放手术组术后37.2%(32/86)注射止痛剂,平均发热3.2d,术后平均住院日9.72±2.15d,伤口疼痛麻木持续9个月,两组间比较差别均有显著性意义(P<0.05)。术后并发症发生率腹腔镜组为1.6%(2/128),主要为手术区积液及出血等;开放手术组为8.1%(7/86),主要为切口感染、肺部感染等。术后病理除1例为肾癌外,其余均符合单纯性肾囊肿的诊断。全部病例随访1～24个月,均未见复发。
结论:腹腔镜肾囊肿去顶减压术治疗肾囊肿,疗效可靠,具有创伤小,痛苦少,术后康复快,并发症少,明显优于开放性手术。具有较高的实用价值,可以完全替代传统的开放性手术,但应做好充分的术前准备,根据术者的习惯选择正确的手术入路途径。
Objective To evaluate the methods and clinical value of laparoscopic renal cyst decortication. To compare the therapeutic effects and advantages of laparoscopic versus open renal cyst unroofing.Methods The 128 cases treated with laparoscopic renal cyst decortication were reviewed retrospectively in the fields of indications to operation, preoperative preparation, approaches, postoperative complications and how to accomplish operation. 128cases were treated by laparoscopic operation with the general anesthesia. 115 cases in transperitoneal and 21 cases in retroperitoneal .All the cases were compared with 86 cases treated by open renal cyst decortication.Then the clinical advantages ,operation time ,blood loss,the durations of hospitalization after operation,etc were studied.Result 70 cases have pains in the back .After opretion the pain of the back resolved in 72.9%(51/70)and improved in 21.4%(15/70) in the laparoscopic group,and in the open surgical group71.2%(37/52) and 21.6%(11/52) (P>0.05).There was no recurrence in both groups. Mean hospitalizations day was 3.62±1.53 days in the laparoscopy group, whereas it was 9.72 ± 2.15 days in the open surgical group. Post operative fever last day mean of 2.1 and 3.2 days in the two groups respectively (P<0.05). There was no need of analgesia afte rlaparoscopy while 37.2%(32/86) of the patients needed analgesia injection after open surgery(P<0.05). Incisional pain or numbness lasted a mean of 2 months in the laparoscopy group and with a mean of 9
months in the open surgery group. The incidence of complication was 1.6%(2/128) in the laparoscopic group being mainly perirenal hematoma and hemorrhage in the operative field. In the open surgery group the complications were infection of incisional wound and infection of lung with amorbidity of 8.1%(7/86). 128 cases were followed up froml to 24 months after surgery. All cases were satisfied with the clinical effect and no obvious complications were found.Conclusion The laparoscopic renal cyst decortication has more advantages of less trauma,quicker recovery,less suffering and complications than open renal cyst decortication and has more practical values, it may take place of open renal cyst decortication. Sufficient preoperative preparations are indispensable to all cases and the approaches must be selected correctly in the light of the habit of operators.
引文
1. Cortersi N, Ferrari P, Zarnbarda E, et al. Diagnosis of bilateral cryptorchidism by laparoscopy. Endoscopy, 1976, 8:33.
2. Lowe DH, Brock WA, Kaplan GW, et al. Laparoscopy for localization of nonpalable testes. J Urol, 1984, 131:728.
3.那彦群,吴刚,郝金瑞.泌尿外科腹腔镜手术141例分析[J].中华外科杂志,1998,36:143-145.
4.亓玉忠,张光永.腹腔镜共有并发症的防治.见:胡三元主编.腹腔镜临床诊治技术.第1版.济南:山东科学技术出版社,2002,59-62
5.金讯波,熊晖,蒋绍博,等.腹腔镜肾盂成形术在UPJO治疗中的应用(附15例报告),山东医药,2003,43(18):1-3.
6.曹献廷 主编.手术解剖学.第一版.北京:人民卫生出版社,1994,672.
7.陆曙炎,陈建国,张焕兴.后腹腔镜手术治疗泌尿系统疾病:附23例报告[J].中华泌尿外科杂志,1997,18:110-112.
8.王杭,王国民,刁伟霖,等.后腹腔镜进路应用解剖学研究.中华外科杂志,2003,41(2):87-89.
9.吴阶平主编.泌尿外科.济南:山东科学技术出版社,1993:884-886.
10. Hobarth K, Kratzik C. Percutaneous sclerosing of kidney cysts with alcohol. Urologe, 1991, 30: 189.
11. Zou SZ, Fan WN, He XH. Percutaneous ultrasound-guided injection ofmorrhuate in the treatment of cystic masses. Brit Jurol, 1991, 68(4): 441-442.
12.那彦群,韩铁山,杨勇,等.应用腹腔镜诊断和治疗泌尿外科疾病.中华外科杂志,1993,31:339.
13.那彦群,李双利,郭应禄,等.腹腔镜切除肾囊肿.中华泌尿外科杂志,1994,15:342.
14.白剑,陈天明,罗顺添,等.经腹膜后间隙腹腔镜下肾囊肿去顶术30例报告.中国内镜杂志,2002,8(1):79-80.
15. Fahlenkamp D, Rassweiler J, Fomara P, et al. Complications of laparoscopic procedures in urology:experience with 2,407 procedures at 4 German centers. J Urol, 1999, 162:765-771.
16. Rassweiler JJ, Seemann O, FredeT, et al. Retroperitoneoscopy: experience with 200 cases. J Urol, 1998, 160:1265-1269.
17.侯小飞,马潞林,黄毅,等.腹膜后腹腔镜手术治疗35例肾囊肿.中国微创外科杂志,2005,5(1):67-68.
18. Vallancien G, Cathelinear X, Baumert H, et al. Complications of transperitoneal laparoscopic surgery in urology:reviewof 1,311 procedures at a simgle center, J Urol, 2002, 168(1):23
19. Rassweiler JJ, Seemann O, Frede T, et al. Retroperitoneoscopy:experience with 200 cases, J Urol, 1998, 160(4):1265
20. Ono Y, Kinukawa T, Hattori R, et al. Laparoscopic radical nephrectomy for renal cell carcinoma: a five years experience. Urology, 1999, 53:280-286.
21. Inderbir S Gill. Needlescopic urology:current status. Urol Clin North Am, 2001, 28(1):71-82.
22.良明.微光机电系统应用与先进医疗工程的研究——微创伤外科手术机器人的研制与发展.机电一体化,2000,6(5):12.
23. Gettman MT, Blute ML, Peschel R, et al. Current status of robotics in urologic laparoscopy. Eur Urol, 2003, 43(2): 106-112.
24. Abbou CC, Hoznek A, Salomon L, et al. Laparoscopic radical prostatectomy with a remote controlled Robot. J Urol, 2001, 165: 1964-1966.
25. Winfield HN, Donovan JF, See WA, et al. Urological laparoscipic surgery. J Urol, 1991, 146:948.
26. Joris J, Thiry E, Paris P, et al. Pain after laparoscopic cholecystectomy: Characteristics and effect of intraperitoneal bupivacaine. Anesth Analg, 1995, 81:379.
27. Sarli R, Costi G, Sanebastiano M, et al. Prospective randomized trial of low-pressure pneum, operitoneums for reduction of shoulder-tip pain following laparoscopy. Surgery, 2000, 87:1161.
28. Elhakin M, Elkott M, Ali NM, et al. Intraperitoneal lidocaine for postoperative pain after laparoscopy. Acta Anesthesiol Scand, 2000, 44:280.
29. Tsimoytamis EC, Siakas P, Tassis A, et al. Intraperitoneal normal saline infusion for postoperative pain after laparoscopic cholecystectomy. World J Surg, 1998, 22:824.
30. Crist DW, Francheschi D, Hugh TB, et al. Complicalions of laparoscopic surgery. Sury Clin North Am, 1993, 73:243-244.
31.郭应禄 主编.泌尿外科内镜诊断治疗学.第一版.北京:北京大学医学出版社,2004.140-181.
32.郭和清,周高标,汪泽厚.等.后腹腔镜肾囊肿去顶术.空军总医院学报,2003,19(4):206-207
33. Webb DR, Redgrave N, Chan Y, et al. Extraperitoneal early experience and evaluation. Austrilian & New Zeala Surgery, 1993;63: 554.
2. Lowe DH, Brock WA, Kaplan GW, et al. Laparoscopy for localization of nonpalable testes. J Urol, 1984, 131:728.
3.那彦群,吴刚,郝金瑞.泌尿外科腹腔镜手术141例分析[J].中华外科杂志,1998,36:143-145.
4.亓玉忠,张光永.腹腔镜共有并发症的防治.见:胡三元主编.腹腔镜临床诊治技术.第1版.济南:山东科学技术出版社,2002,59-62
5.金讯波,熊晖,蒋绍博,等.腹腔镜肾盂成形术在UPJO治疗中的应用(附15例报告),山东医药,2003,43(18):1-3.
6.曹献廷 主编.手术解剖学.第一版.北京:人民卫生出版社,1994,672.
7.陆曙炎,陈建国,张焕兴.后腹腔镜手术治疗泌尿系统疾病:附23例报告[J].中华泌尿外科杂志,1997,18:110-112.
8.王杭,王国民,刁伟霖,等.后腹腔镜进路应用解剖学研究.中华外科杂志,2003,41(2):87-89.
9.吴阶平主编.泌尿外科.济南:山东科学技术出版社,1993:884-886.
10. Hobarth K, Kratzik C. Percutaneous sclerosing of kidney cysts with alcohol. Urologe, 1991, 30: 189.
11. Zou SZ, Fan WN, He XH. Percutaneous ultrasound-guided injection ofmorrhuate in the treatment of cystic masses. Brit Jurol, 1991, 68(4): 441-442.
12.那彦群,韩铁山,杨勇,等.应用腹腔镜诊断和治疗泌尿外科疾病.中华外科杂志,1993,31:339.
13.那彦群,李双利,郭应禄,等.腹腔镜切除肾囊肿.中华泌尿外科杂志,1994,15:342.
14.白剑,陈天明,罗顺添,等.经腹膜后间隙腹腔镜下肾囊肿去顶术30例报告.中国内镜杂志,2002,8(1):79-80.
15. Fahlenkamp D, Rassweiler J, Fomara P, et al. Complications of laparoscopic procedures in urology:experience with 2,407 procedures at 4 German centers. J Urol, 1999, 162:765-771.
16. Rassweiler JJ, Seemann O, FredeT, et al. Retroperitoneoscopy: experience with 200 cases. J Urol, 1998, 160:1265-1269.
17.侯小飞,马潞林,黄毅,等.腹膜后腹腔镜手术治疗35例肾囊肿.中国微创外科杂志,2005,5(1):67-68.
18. Vallancien G, Cathelinear X, Baumert H, et al. Complications of transperitoneal laparoscopic surgery in urology:reviewof 1,311 procedures at a simgle center, J Urol, 2002, 168(1):23
19. Rassweiler JJ, Seemann O, Frede T, et al. Retroperitoneoscopy:experience with 200 cases, J Urol, 1998, 160(4):1265
20. Ono Y, Kinukawa T, Hattori R, et al. Laparoscopic radical nephrectomy for renal cell carcinoma: a five years experience. Urology, 1999, 53:280-286.
21. Inderbir S Gill. Needlescopic urology:current status. Urol Clin North Am, 2001, 28(1):71-82.
22.良明.微光机电系统应用与先进医疗工程的研究——微创伤外科手术机器人的研制与发展.机电一体化,2000,6(5):12.
23. Gettman MT, Blute ML, Peschel R, et al. Current status of robotics in urologic laparoscopy. Eur Urol, 2003, 43(2): 106-112.
24. Abbou CC, Hoznek A, Salomon L, et al. Laparoscopic radical prostatectomy with a remote controlled Robot. J Urol, 2001, 165: 1964-1966.
25. Winfield HN, Donovan JF, See WA, et al. Urological laparoscipic surgery. J Urol, 1991, 146:948.
26. Joris J, Thiry E, Paris P, et al. Pain after laparoscopic cholecystectomy: Characteristics and effect of intraperitoneal bupivacaine. Anesth Analg, 1995, 81:379.
27. Sarli R, Costi G, Sanebastiano M, et al. Prospective randomized trial of low-pressure pneum, operitoneums for reduction of shoulder-tip pain following laparoscopy. Surgery, 2000, 87:1161.
28. Elhakin M, Elkott M, Ali NM, et al. Intraperitoneal lidocaine for postoperative pain after laparoscopy. Acta Anesthesiol Scand, 2000, 44:280.
29. Tsimoytamis EC, Siakas P, Tassis A, et al. Intraperitoneal normal saline infusion for postoperative pain after laparoscopic cholecystectomy. World J Surg, 1998, 22:824.
30. Crist DW, Francheschi D, Hugh TB, et al. Complicalions of laparoscopic surgery. Sury Clin North Am, 1993, 73:243-244.
31.郭应禄 主编.泌尿外科内镜诊断治疗学.第一版.北京:北京大学医学出版社,2004.140-181.
32.郭和清,周高标,汪泽厚.等.后腹腔镜肾囊肿去顶术.空军总医院学报,2003,19(4):206-207
33. Webb DR, Redgrave N, Chan Y, et al. Extraperitoneal early experience and evaluation. Austrilian & New Zeala Surgery, 1993;63: 554.