摘要
目的 探讨肾肿瘤微创肾部分切除术的通用手术模式.方法 患者女,53岁,因"体检发现右肾占位3 d"于四川省人民医院入院治疗.17年前因左肾结石行左肾切除术,高血压病史3年,规律服药.外院泌尿系超声提示右肾下极中等稍高回声结节,大小约2.0 cm×1.5 cm.因患者对造影剂过敏,故入院仅行平扫肾及肾上腺薄层CT,结果提示未见明显异常.故再行平扫上中腹磁共振成像(magnetic resonance imaging,MRI)提示右肾下极见结节状异常信号影,直径约1.8 cm.术前血清肌酐值为82 µmol/L.术前诊断为右肾肿瘤及高血压.故拟行腹腔镜下肾部分切除术.手术采用经腹入路,左侧卧位70°～80°,建立气腹.松解肝肾韧带,解剖肾门,暴露肾动脉.定位肿瘤(可使用术中超声辅助定位肿瘤),使用单极电凝绕肿瘤边界绘出环形标识线,随后阻断肾动脉.沿标识线锐性切开肿瘤边缘肾皮质,沿辐射状肾髓质采用"切"和"劈"的切割方法直达肾窦,直至见到肾窦脂肪,转为横向,平行推进,切除肿瘤.使用3-0 V-Loc缝合线以连续的缝合方式闭合缺损,最后使用Hem-o-lok阻断夹锁定缝线.缝合完成后,取下阻断夹.气腹压力降低至5 mmHg(1 mmHg=0.133 kPa),持续5～10 min,评估肾脏出血.结果 手术顺利,无输血,无中转开腹手术,手术时间约120 min,术中出血量约100 ml,热缺血时间约20 min,术中及术后无相关并发症.术后住院6 d,术后第2天复查肌酐值为103 µmol/L,术后第6天复查肌酐值为91 µmol/L.术后病理:右肾透明细胞癌,切缘阴性,分期pTIN0M0.术后6月肌酐值为83.6 μmol/L,无局部及远处复发.结论 通过标记边界、锐性切割、层面剥离、保护基底、单层闭合的肾部分切除模式,顺利切除肿瘤.术后随访肾功能满意,肿瘤无复发,总体安全性、有效性良好.
Abstract
Objective To explore the standardized surgical approach for minimally invasive partial nephrectomy for renal tumors.Methods The patient is a 53-year-old female who was admitted to Sichuan Provincial People's Hospital due to the discovery of a right renal mass during a physical examination for 3 days.Seventeen years ago,she underwent left nephrectomy for renal calculi.She has a history of hypertension for 3 years,which is well-controlled with regular medication.The urinary system ultrasound indicated a moderately high echogenic nodule in the lower pole of the right kidney,measuring approximately 2.0 cm×1.5 cm.Due to the patient's allergy to contrast agents,only plain kidney and adrenal thin-layer CT scan was performed upon admission,which showed no obvious abnormalities.Therefore,a plain upper abdominal magnetic resonance imaging(MR1)scan was performed,which revealed a nodular abnormal signal in the lower pole of the right kidney,with a diameter of approximately 1.8 cm.The preoperative serum creatinine level was 82 μmol/L.The preoperative diagnosis was right renal tumor and hypertension.Therefore,laparoscopic partial nephrectomy was planned.The surgery was performed using a transabdominal approach,with the patient in a left lateral decubitus position of 70° to 80°,and pneumoperitoneum was established.The hepatorenal ligament was dissected,and the renal hilum was exposed to identify the renal artery.The tumor was localized(intraoperative ultrasound can be used for tumor localization),and a circular marking line was drawn around the tumor using monopolar electrocautery.Subsequently,the renal artery was occluded.The renal was sharply incised along the marking line,reaching around the tumor,and then a"cut and split"method was used along the radial renal medulla to reach the renal sinus until the renal sinus fat was visualized.The incision was then made horizontally and pushed parallelly to remove the tumor.The defect was closed using 3-0 V-Loc suture in a continuous manner,and Hem-o-lok clips were used to secure the suture.After the closure,the clips were removed.The pneumoperitoneum pressure was reduced to 5 mmHg(1 mmHg=0.133 kPa)and maintained for 5 to 10 minutes to evaluate renal bleeding.Results The surgery was successful,with no blood transfusion or conversion to open surgery.The operation time was approximately 120 minutes,with an intraoperative blood loss of about 100 ml and a warm ischemia time of approximately 20 minutes.There were no intraoperative or postoperative complications.The patient was hospitalized for 6 days,and on the second day after surgery,the serum creatinine level was 103 μmol/L,which decreased to 91 μmol/L on the sixth day after surgery.The postoperative pathology revealed clear cell carcinoma of the right kidney,with negative margins and a stage of pTIN0M0.The serum creatinine level at 6 months postoperatively was 83.6 μmol/L,and there was no local or distant recurrence.Conclusions The standardized surgical approach of marking the boundaries,sharp dissection,layered peeling,protecting the base,and single-layer closure for partial nephrectomy allowed for successful tumor resection.The postoperative follow-up showed satisfactory renal function and no tumor recurrence,indicating good overall safety and effectiveness.
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