經(jīng)臍單孔腎癌根治術(shù)課件

1、經(jīng)臍單孔腎癌根治術(shù)LESS radical nephrectomy北京大學(xué)第三醫(yī)院泌尿外科 馬潞林 張帆 張樹(shù)棟經(jīng)臍單孔腎癌根治術(shù)經(jīng)臍單孔腎癌根治術(shù)LESS radical nephrLESS的概念LESS: Laparo-endoscopic Single-Site SurgeryLESS是指通過(guò)單一通道利用傳統(tǒng)腹腔鏡器械或新式器械設(shè)備進(jìn)行的微創(chuàng)手術(shù)操作；在LESS手術(shù)中，經(jīng)臍建立手術(shù)通道被大多數(shù)手術(shù)采用，且可以隱藏疤痕，稱為經(jīng)臍單孔腔鏡手術(shù)（Umbilical Laparo-endoscopic Single-Site Surgery，U-LESS）。經(jīng)臍單孔腎癌根治術(shù)LESS的概念經(jīng)臍單

2、孔腎癌根治術(shù)LESS的挑戰(zhàn)操作缺乏三角關(guān)系器械間“打架”內(nèi)鏡角度改變?cè)斐傻牟贿m經(jīng)臍單孔腎癌根治術(shù)LESS的挑戰(zhàn)經(jīng)臍單孔腎癌根治術(shù)Storze單孔通道經(jīng)臍單孔腎癌根治術(shù)Storze單孔通道經(jīng)臍單孔腎癌根治術(shù)制作方便，經(jīng)濟(jì)實(shí)用；對(duì)于不同手術(shù)可任意更換不同Trocar；可以高溫滅菌，反復(fù)使用；內(nèi)徑呈螺旋狀，可固定在切口中。我科自制單孔通道經(jīng)臍單孔腎癌根治術(shù)制作方便，經(jīng)濟(jì)實(shí)用；我科自制單孔通道經(jīng)臍單孔腎癌根治術(shù) T R O C進(jìn)口單孔TROC直徑3cm左右，操作時(shí)困難取標(biāo)本需延長(zhǎng)切口，腎癌根治術(shù)的切口至少需58cm取直徑5cm的朔料瓶口，長(zhǎng)約5cm,系手套而成繞臍縱切口長(zhǎng)6cm可在一定程度上緩解器械間

3、的三角關(guān)系經(jīng)臍單孔腎癌根治術(shù) T R O C進(jìn)口單孔TROC直徑3經(jīng)臍LESS腎癌根治術(shù)手術(shù)體位健側(cè)臥位，抬高腰橋，傾斜30度。經(jīng)臍單孔腎癌根治術(shù)經(jīng)臍LESS腎癌根治術(shù)手術(shù)體位健側(cè)臥位，抬高腰橋，傾斜30度繞臍切口，必要時(shí)切口向上延長(zhǎng)插入器械及腹腔鏡經(jīng)臍LESS腎癌根治術(shù)手術(shù)入路經(jīng)臍單孔腎癌根治術(shù)經(jīng)臍LESS腎癌根治術(shù)手術(shù)入路經(jīng)臍單孔腎癌根治術(shù)早期LESS的通道設(shè)計(jì)：多個(gè)傳統(tǒng)腹腔鏡Trocar同時(shí)插入臍部切口。經(jīng)臍單孔腎癌根治術(shù)早期LESS的通道設(shè)計(jì)：多個(gè)傳統(tǒng)腹腔鏡Trocar同時(shí)插入臍新式單孔通道 Triport經(jīng)臍單孔腎癌根治術(shù)新式單孔通道經(jīng)臍單孔腎癌根治術(shù)我科自制單孔通道 Trocar在

4、手套內(nèi)的位置不受限制，長(zhǎng)度可以靈活調(diào)節(jié)，從而增加了操作器械的活動(dòng)范圍，擴(kuò)大了手術(shù)的可視空間。經(jīng)臍單孔腎癌根治術(shù)我科自制單孔通道 Trocar在手套內(nèi)的位置經(jīng)臍單孔腎癌根治術(shù)早期先做左側(cè)經(jīng)臍單孔腎癌根治術(shù) 10 例，因左側(cè)無(wú)肝，相對(duì)容易早期選擇下極腫瘤熟練后可行右側(cè)腎癌根治性切除，最大直徑8cm經(jīng)臍單孔腎癌根治術(shù)經(jīng)臍單孔腎癌根治術(shù)早期先做左側(cè)經(jīng)臍單孔腎癌根治術(shù) 10 例，多支腎動(dòng)脈的處理經(jīng)臍單孔腎癌根治術(shù)多支腎動(dòng)脈的處理經(jīng)臍單孔腎癌根治術(shù)CT增強(qiáng)經(jīng)臍單孔腎癌根治術(shù)CT增強(qiáng)經(jīng)臍單孔腎癌根治術(shù)CT重建經(jīng)臍單孔腎癌根治術(shù)CT重建經(jīng)臍單孔腎癌根治術(shù)經(jīng)臍行右側(cè)腎癌根治性切除尋找輸尿管經(jīng)臍單孔腎癌根治術(shù)經(jīng)臍

5、行右側(cè)腎癌根治性切除尋找輸尿管經(jīng)臍單孔腎癌根治術(shù)阻斷腎動(dòng)脈經(jīng)臍單孔腎癌根治術(shù)阻斷腎動(dòng)脈經(jīng)臍單孔腎癌根治術(shù)共4支腎動(dòng)脈切斷腎動(dòng)脈分支經(jīng)臍單孔腎癌根治術(shù)共4支腎動(dòng)脈切斷腎動(dòng)脈分支經(jīng)臍單孔腎癌根治術(shù)切斷腎靜脈經(jīng)臍單孔腎癌根治術(shù)切斷腎靜脈經(jīng)臍單孔腎癌根治術(shù)Raman JD, et al. Single-incision,umbilical laparoscopic versus conventional laparoscopic nephrectomy: a comparison perioperative outcomes and short-term measures of convalescen

6、ce. Eur Urol 2009; 55:11981206LESS與傳統(tǒng)腹腔鏡對(duì)比研究經(jīng)臍單孔腎癌根治術(shù)Raman JD, et al. Single-incisiRaybourn JH 3rd, Rane A, Sundaram CP. Laparoendoscopic Single-site Surgery for Nephrectomy as a Feasible Alternative to Traditional Laparoscopy. Urology. 2009 Jul 21.相比于傳統(tǒng)腹腔鏡，LESS手術(shù)的安全性已經(jīng)被證實(shí)；LESS手術(shù)在手術(shù)時(shí)間和手術(shù)并發(fā)癥方面與傳統(tǒng)腹腔鏡

7、無(wú)顯著性差異，對(duì)于單純腎臟切除術(shù)是可行的方法；LESS手術(shù)的美容效果（無(wú)疤痕）是顯而易見(jiàn)的。LESS與傳統(tǒng)腹腔鏡對(duì)比研究經(jīng)臍單孔腎癌根治術(shù)Raybourn JH 3rd, Rane A, Sunda后腹腔鏡術(shù)后經(jīng)臍LESS術(shù)后經(jīng)臍LESS腎癌根治術(shù)術(shù)后切口經(jīng)臍單孔腎癌根治術(shù)后腹腔鏡術(shù)后經(jīng)臍LESS術(shù)后經(jīng)臍LESS腎癌根治術(shù)術(shù)后切口經(jīng)LESS RN與RLPRN的技術(shù)特點(diǎn)比較LESS腎癌根治術(shù)后腹腔鏡腎癌根治術(shù)手術(shù)空間大，視野開(kāi)闊手術(shù)空間相對(duì)狹小手術(shù)器械平行排列，相互干擾手術(shù)器械存在三角關(guān)系，便于操作腎動(dòng)脈尋找和處理較為困難，尤其對(duì)于多支腎動(dòng)脈尋找和顯露腎血管較為容易腎靜脈容易顯露腎臟上極游離困難一般情況腎臟游離較容易，但當(dāng)大腫瘤位于腹側(cè)時(shí)游離困難經(jīng)臍單孔腎癌根治術(shù)LESS RN與RLPRN的技術(shù)特點(diǎn)比較LESS腎癌根治術(shù)后經(jīng)臍LESS腎臟手術(shù)的優(yōu)勢(shì)切口隱蔽，美容