4K fluorescent laparoscopic extended CME plus D3 lymphadenectomy with No.206 and No.204 lymph node dissection for ascending colon cancer and hepatic flexure cancer
4K fluorescent laparoscopic extended CME plus D3 lymphadenectomy with No.206 and No.204 lymph node dissection for ascending colon cancer and hepatic flexure cancer
燕速 1霍博文 1徐惠宁1
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作者信息
1. 810012 西宁,青海大学附属医院胃肠肿瘤外科
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摘要
4K荧光腹腔镜扩大右半结肠全结肠系膜切除术联合D3淋巴结清扫术,适用于升结肠癌及结肠肝曲癌(TNM分期为T1-4aN0-2M0)的患者.手术入路采取以中央入路优先的头尾相结合入路,手术过程遵循无菌、无瘤、不接触原则(do not touch it)和整块切除原则(En-bloc),手术流程保持连贯性.手术全程在膜解剖指导下完成,保证背侧的泌尿生殖筋膜层和结肠系膜背侧叶筋膜面的光整,手术视野内的膜性结构要完整无破损,避免脂肪颗粒的溢出.D3根治术的内侧界以肠系膜上动脉的右侧缘为边界,保留肠系膜上动脉表面的神经丛,在荧光示踪导航下显露回结肠血管、右结肠血管及中结肠血管,并在血管根部结扎和切断,完成淋巴结清扫.充分显露肠系膜上静脉的外科干及Henle干,避免静脉各属支出血.维持适度张力,切开膜桥并进入到右侧Toldt间隙,辨识和保持完整的膜结构是手术的关键.
Abstract
4K fluorescent laparoscopic extended right hemicolectomy with total mesocolon excision combined with D3 lymph node dissection is indicated for patients with ascending colon cancer and colonic hepatic flexure cancer,staged as T1-4aN0-2M0.The surgical approach was a medial approach in priority combined with cranial-to-caudal approach.The procedure should follow the principles of asepsis and tumor-free,do not touch it and en-bloc resection,and keep the surgical process coherent.The whole procedure is performed under the guidance of membrane anatomy,ensuring that the dorsal urogenital fascial layer and the dorsal layer of the mesocolon are smooth,and the membrane structures in the surgical field should be intact and unbroken,so as to avoid the spillage of adipose particles.The medial border of D3 radical dissection is defined by the right margin of the superior mesenteric artery,preserving the nerve plexus on the surface of the superior mesenteric artery,and the ileocolic vascular,the right colic vascular,and the middle colic vascular should be exposed under the fluorescent tracer navigation,and the D3 lymphadenectomy was performed by ligating and transecting at the roots of the vessels as mentioned the above.The surgical trunk of the superior mesenteric vein and the Henle's trunk were fully exposed to avoid bleeding of the venous branches.The critical technique of CME and D3 lymphadenectomy is maintaining,proper tension among tissues and organs,incising the membrane bridge,entering the right Toldtfascial space,identifying and keeping the intact membranous structure.
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