腹腔镜肾部分切除术(二)
转载请注明来自丁香园
Suturing the bed of the PN defect with a running 2/0 polyglactin on a CT-1 needle aims to achieve:
1) precise water-tight repair of any pelvicalyceal system entry;
2) oversuturing of all sizeable transected intrarenal blood vessels.
If necessary, individual figureof-eight sutures can be placed at the precise location of a large transected blood vessel in the parenchyma.
Retrograde injection of dilute indigo carmine through the previously placed ureteric catheter precisely identifies any calyceal entry, and helps to confirm a watertight pelvicalyceal suture repair.
用2-0的polyglactin线缝合切除部分肾脏实质后的创面以达到：
1）精确修补肾盂肾盏系统以防漏尿；
2）缝合比较大的横断性肾内血管。如有必要，行8 字缝合能精确地在肾实质中对横断血管进行精确定位。
通过先前置入的输尿管导管逆行注射稀释的靛胭脂红仔细辨别任何与肾盏的相通，并有助于证实避免缝合修补肾盂肾盏的漏尿。
12）and 13）
Parenchymal renorraphy is performed with #1 polyglactin on a CTX needle (suture length 30 cm) over a pre-prepared oxidized cellulose bolster (Surgicel, Johnson & Johnson, New Brunswick, NJ, USA), which is positioned underneath the individual suture loops. A Hem-o-lok clip placed previously 10 cm from the tail end of the suture, serves as a pledget. The meticulous placing of renal parenchymal sutures along a planned angle and depth of needle passage is important to prevent multiple needle passages. A biological haemostatic agent, gelatine-matrix thrombin sealant (Floseal) is layered directly on the PN bed underneath the Surgicel bolster. A 5-mm metal applicator is used for injection. After suture tightening to firmly compress the bolster onto the PN bed, another Hem-o-lok clip is placed on the exiting suture flush with the parenchyma to maintain consistent pressure. The two suture tails are tightly tied together with a surgeon’s knot. Reconstructing the entire parenchymal defect typically requires 3–5 renorraphy sutures. Bleeding from the edges of a substantive PN defect can occur if inadequate parenchymal compression is attempted by merely placing a clip as a pledget on either end of the suture. We think that effective coaptation of the edges of the parenchymal defect requires tying the suture tails across the bolster.
肾实质止血用1号polyglactin。
HILAR UNCLAMPING 松开肾门
The i.v. administration of 12.5 g mannitol and 10–20 mg furosemide is repeated 2–3 min before hilar unclamping. The Satinsky clamp is unclamped and maintained in place to assess the adequacy of haemostasis from the PN bed. Once haemostasis is confirmed, the clamp is carefully removed under direct vision. The warm ischaemia time is noted. Haemostasis is re-checked laparoscopically after desufflating the abdomen for 5–10 min.
在松开肾门前静脉注射12.5g甘露醇以及10-20mg速尿并2-3min重复一次。松开Satinsky 钳评估部分肾床止血是否完善。证实止血后，直视下退钳。记录热缺血时间。在腹部减压5-10min后再次确认止血确实。
LAPAROSCOPIC EXIT
Slight extension of one of the port-site incisions allows intact extraction of the specimen previously entrapped in an Endocatch bag (USSC, Norwalk, CT, USA). After transperitoneal LPN we place a Jackson-Pratt drain. After retroperitoneoscopic LPN, we leave a Penrose drain with no suction. The Carter-Thompson device is used for the fascial closure of the 10/12-mm port sites. The surgeons must inspect the specimen with the pathologist, to confirm negative margins before terminating the procedure.
退出腹腔镜
RENAL HYPOTHERMIA
肾低温
Although transient renal hilar clamping provides a bloodless operative field, it results in warm ischaemia. As renal metabolic activity is almost completely suspended at 5–20 °C, hypothermia affords cellular protection and minimizes renal injury after ischaemia. As such, hypothermia should be established in complex cases where the warm ischaemia time is anticipated to be considerably >30 min. Our technique of laparoscopic ice-slush hypothermia during LPN consists of:
1) complete mobilization of the kidney;
2) US-guided tumour identification and circumferential scoring of the renal capsule along the proposed line of resection;
3) i.v. administration of mannitol (12.5 g);
4) placing an Endocatch II bag around the kidney with the drawstring closed around the hilum;
5) Satinsky clamping of the en bloc renal hilum;
6) retrieval of the bottom end of the bag outside the abdomen, through an inferior pararectal port site;
7) opening the exteriorized bag and using pre-loaded syringes to rapidly fill the intra-abdominal bag with ice slurry (600–900 mL) within 4–7 min;
8) closure of the open end of the bag with a tie and reinserting into the abdomen;
9) incising open the bag after 10 min (necessary to achieve core renal cooling of 5–19°C) and removing the ice surrounding only the tumour area;
10) completion of LPN in the usual fashion.
POSTOPERATIVE CARE
术后监护
Bed rest for 24 h followed by gradual mobilization is advised. The ureteric and Foley catheters are removed on the morning of the second day. The abdominal drain is removed when drainage is < 50 mL/day for 3 consecutive days. After discharge, the patient is advised to restrict activity for 2 weeks to prevent potential jarring of the renal remnant. The initial follow-up at 4 weeks includes a physical examination, serum haemoglobin and haematocrit estimates, and serum creatinine measurement. At 3 months, a MAG-3 radionuclide renal scan is taken. Screening for hyperfiltration nephropathy in patients with a solitary remnant kidney includes a 24-h urinary protein measurement. Patients with pathologically confirmed renal cancer have CT and a chest X-ray at 6 months or 1 year.
建议术后卧床24小时。输尿管导管和Foley尿管在第二日清晨即可拔除。当腹部引流小于50毫升每天持续3天时即可拔除。出院后，建议患者限制活动2 周以防残余肾实质潜在的震动。随访的前4周包括体格检查，血红蛋白以及红细胞压积评估，测定血清肌肝。术后3月，进行放射性核素扫描筛查。证实为肾癌患者在术后6个月或1年进行CT以及胸片检查。
肾部分切除术如何控制止血以及主要的止血手段
1、控制止血：
1）阻断肾蒂，优点在于可以清楚的观察肾实质．由此更好的辨明肿块和手术切缘。进行准确的手术切除。在LPN中，暂时性的阻断肾蒂在短期内不会损害到肾功能。在预期可能出现大出血或要损伤集合系统的LPN中，阻断肾蒂是一种安全的技术。
2）器械运用：比如用Santisky钳或裁剪的止血带夹住肾动静脉，阻断肾蒂，用冷刀行肾部分切除术；再比如TissueLink Floating Bal器械可以有效控制出血，保持清晰视野。
2、主要止血手段：
1）应用具有止血凝血功能的肾脏切割器械，Barret等对单极电刀、双极电刀、超声刀3者的止血效果进行动物实验比较，认为超声刀较其他两者好；具体的止血器械方法的介绍应用下有参考文献（见下）。
2）肾创面涂敷止血材料，在临床实践中，多将切割器械与创面涂敷止血材料结合使用。
3）腹腔镜下直接缝合、缝扎止血，这在腹腔镜下有一定的难度，对术者的腔镜下操作技术要求较高。
最近的研究中有明胶基质凝血酶组织封闭剂，在动物试验中运用人白蛋白组织焊接等。
腹腔镜肾部分切除术的现状 党鸿毅 综述 韩启光审校 《国际医学泌尿系统分册》2003年23卷2期
1) precise water-tight repair of any pelvicalyceal system entry;
2) oversuturing of all sizeable transected intrarenal blood vessels.
If necessary, individual figureof-eight sutures can be placed at the precise location of a large transected blood vessel in the parenchyma.
Retrograde injection of dilute indigo carmine through the previously placed ureteric catheter precisely identifies any calyceal entry, and helps to confirm a watertight pelvicalyceal suture repair.
用2-0的polyglactin线缝合切除部分肾脏实质后的创面以达到：
1）精确修补肾盂肾盏系统以防漏尿；
2）缝合比较大的横断性肾内血管。如有必要，行8 字缝合能精确地在肾实质中对横断血管进行精确定位。
通过先前置入的输尿管导管逆行注射稀释的靛胭脂红仔细辨别任何与肾盏的相通，并有助于证实避免缝合修补肾盂肾盏的漏尿。
12）and 13）
Parenchymal renorraphy is performed with #1 polyglactin on a CTX needle (suture length 30 cm) over a pre-prepared oxidized cellulose bolster (Surgicel, Johnson & Johnson, New Brunswick, NJ, USA), which is positioned underneath the individual suture loops. A Hem-o-lok clip placed previously 10 cm from the tail end of the suture, serves as a pledget. The meticulous placing of renal parenchymal sutures along a planned angle and depth of needle passage is important to prevent multiple needle passages. A biological haemostatic agent, gelatine-matrix thrombin sealant (Floseal) is layered directly on the PN bed underneath the Surgicel bolster. A 5-mm metal applicator is used for injection. After suture tightening to firmly compress the bolster onto the PN bed, another Hem-o-lok clip is placed on the exiting suture flush with the parenchyma to maintain consistent pressure. The two suture tails are tightly tied together with a surgeon’s knot. Reconstructing the entire parenchymal defect typically requires 3–5 renorraphy sutures. Bleeding from the edges of a substantive PN defect can occur if inadequate parenchymal compression is attempted by merely placing a clip as a pledget on either end of the suture. We think that effective coaptation of the edges of the parenchymal defect requires tying the suture tails across the bolster.
肾实质止血用1号polyglactin。
HILAR UNCLAMPING 松开肾门
The i.v. administration of 12.5 g mannitol and 10–20 mg furosemide is repeated 2–3 min before hilar unclamping. The Satinsky clamp is unclamped and maintained in place to assess the adequacy of haemostasis from the PN bed. Once haemostasis is confirmed, the clamp is carefully removed under direct vision. The warm ischaemia time is noted. Haemostasis is re-checked laparoscopically after desufflating the abdomen for 5–10 min.
在松开肾门前静脉注射12.5g甘露醇以及10-20mg速尿并2-3min重复一次。松开Satinsky 钳评估部分肾床止血是否完善。证实止血后，直视下退钳。记录热缺血时间。在腹部减压5-10min后再次确认止血确实。
LAPAROSCOPIC EXIT
Slight extension of one of the port-site incisions allows intact extraction of the specimen previously entrapped in an Endocatch bag (USSC, Norwalk, CT, USA). After transperitoneal LPN we place a Jackson-Pratt drain. After retroperitoneoscopic LPN, we leave a Penrose drain with no suction. The Carter-Thompson device is used for the fascial closure of the 10/12-mm port sites. The surgeons must inspect the specimen with the pathologist, to confirm negative margins before terminating the procedure.
退出腹腔镜
RENAL HYPOTHERMIA
肾低温
Although transient renal hilar clamping provides a bloodless operative field, it results in warm ischaemia. As renal metabolic activity is almost completely suspended at 5–20 °C, hypothermia affords cellular protection and minimizes renal injury after ischaemia. As such, hypothermia should be established in complex cases where the warm ischaemia time is anticipated to be considerably >30 min. Our technique of laparoscopic ice-slush hypothermia during LPN consists of:
1) complete mobilization of the kidney;
2) US-guided tumour identification and circumferential scoring of the renal capsule along the proposed line of resection;
3) i.v. administration of mannitol (12.5 g);
4) placing an Endocatch II bag around the kidney with the drawstring closed around the hilum;
5) Satinsky clamping of the en bloc renal hilum;
6) retrieval of the bottom end of the bag outside the abdomen, through an inferior pararectal port site;
7) opening the exteriorized bag and using pre-loaded syringes to rapidly fill the intra-abdominal bag with ice slurry (600–900 mL) within 4–7 min;
8) closure of the open end of the bag with a tie and reinserting into the abdomen;
9) incising open the bag after 10 min (necessary to achieve core renal cooling of 5–19°C) and removing the ice surrounding only the tumour area;
10) completion of LPN in the usual fashion.
POSTOPERATIVE CARE
术后监护
Bed rest for 24 h followed by gradual mobilization is advised. The ureteric and Foley catheters are removed on the morning of the second day. The abdominal drain is removed when drainage is < 50 mL/day for 3 consecutive days. After discharge, the patient is advised to restrict activity for 2 weeks to prevent potential jarring of the renal remnant. The initial follow-up at 4 weeks includes a physical examination, serum haemoglobin and haematocrit estimates, and serum creatinine measurement. At 3 months, a MAG-3 radionuclide renal scan is taken. Screening for hyperfiltration nephropathy in patients with a solitary remnant kidney includes a 24-h urinary protein measurement. Patients with pathologically confirmed renal cancer have CT and a chest X-ray at 6 months or 1 year.
建议术后卧床24小时。输尿管导管和Foley尿管在第二日清晨即可拔除。当腹部引流小于50毫升每天持续3天时即可拔除。出院后，建议患者限制活动2 周以防残余肾实质潜在的震动。随访的前4周包括体格检查，血红蛋白以及红细胞压积评估，测定血清肌肝。术后3月，进行放射性核素扫描筛查。证实为肾癌患者在术后6个月或1年进行CT以及胸片检查。
肾部分切除术如何控制止血以及主要的止血手段
1、控制止血：
1）阻断肾蒂，优点在于可以清楚的观察肾实质．由此更好的辨明肿块和手术切缘。进行准确的手术切除。在LPN中，暂时性的阻断肾蒂在短期内不会损害到肾功能。在预期可能出现大出血或要损伤集合系统的LPN中，阻断肾蒂是一种安全的技术。
2）器械运用：比如用Santisky钳或裁剪的止血带夹住肾动静脉，阻断肾蒂，用冷刀行肾部分切除术；再比如TissueLink Floating Bal器械可以有效控制出血，保持清晰视野。
2、主要止血手段：
1）应用具有止血凝血功能的肾脏切割器械，Barret等对单极电刀、双极电刀、超声刀3者的止血效果进行动物实验比较，认为超声刀较其他两者好；具体的止血器械方法的介绍应用下有参考文献（见下）。
2）肾创面涂敷止血材料，在临床实践中，多将切割器械与创面涂敷止血材料结合使用。
3）腹腔镜下直接缝合、缝扎止血，这在腹腔镜下有一定的难度，对术者的腔镜下操作技术要求较高。
最近的研究中有明胶基质凝血酶组织封闭剂，在动物试验中运用人白蛋白组织焊接等。
腹腔镜肾部分切除术的现状 党鸿毅 综述 韩启光审校 《国际医学泌尿系统分册》2003年23卷2期
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