腹腔镜肾部分切除术(一)
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借外文文献翻译的手术步骤图示讨论腹腔镜肾部分切除术
Massimiliano Spaliviero and Inderbir S. Gill
Section of Laparoscopic and Robotic Surgery, Glickman Urological Institute,
The Cleveland Clinic Foundation, Cleveland, OH, USA
缩略语：open partial nephrectomy （OPN），laparoscopic PN （LPN）
For transperitoneal LPN, the patient is placed in a 45–60°lateral position on the operating table.
经腹腹腔镜肾部分切除术，患者于术台上摆45-60度侧卧位。
To prevent postoperative neuromuscular strain, the head, neck, arms, axilla, hips, legs and ankles are each ergonomically placed in a neutral position and generously padded with foam padding. Care is taken not to obstruct any i.v. line. The patient is secured to the operating table at the level of chest and iliac crest, using 15 cm silk tape, thus permitting safe table rotation during LPN.
为预防术后神经肌肉紧张，头部，颈部，手臂，腋区，臀部，腿部以及踝关节都应置于一种适中位置并用泡沫垫起。（体位上的）护理不应阻碍静脉通道。患者应确保在胸部至髂骨之间的水平术台上，用15cm带子固定，在腹腔镜肾部分切除术中能安全旋转。
To obtain pneumoperitoneum, a Veress needle is placed into the ipsilateral lower abdominal quadrant along the midclavicular line. CO2 pneumoperitoneum (15 mmHg) is achieved and four secondary ports are placed: a 12-mm laparoscopic port (primary port) placed lateral to the rectus muscle at the level of the umbilicus; a subcostal port lateral to the rectus muscle at the 12th rib costochondral margin (on the right side; this subcostal 10/ 12 mm port allows passage of suture needles for the right-handed surgeon; on the left side, this subcostal port is typically a 5-mm port); a 10/12 mm port for the laparoscopic camera is placed 3 cm inferior and medial to the subcostal port; a 5-mm port is inserted at the mid-axillary line near the tip of the 11th rib, and used to place lateral counter-traction during renal hilar dissection, and to grasp renorraphy sutures during renal parenchymal repair; and finally, a 10/12-mm port is placed in the suprapubic area at the lateral edge of the rectus muscle for insertion of the Satinsky vascular clamp. This standard configuration can be varied according to the individual patient anatomy and tumour location.
气腹建立：沿锁骨中线置入Veress针进同侧下腹，建立气腹通入二氧化碳达15mmHg；置入4个辅助通道：12mm腹腔镜通道（主通道）位于脐水平腹直肌的外侧缘进入；侧通道位于腹直肌线的第12肋缘（在右侧，此肋骨下10/ 12mm通道可允许右手外科医师的使用缝合针通过；在左侧，肋骨下的通道一般为5mm）；在肋骨内侧以下3公分设置一10/12 mm通道置入腹腔镜摄像（系统），在近11肋的腋中线设置5mm通道以便置入（器械）在肾门切除时对抗牵拉以及在肾实质修补时抓持renorraphy缝合。最后在耻骨弓上区域的腹直肌外侧缘设置10/12-mm通道以置入Satinsky血管夹。标准的通道设置依赖于病人个体解剖及肿瘤定位。
During right LPN, the liver is retracted anteriorly and cephalad to expose the renal upper pole. During left LPN, the spleen, splenic flexure and pancreas are reflected medially. On either side, the ipsilateral colon is mobilized to expose the renal hilum. On the right side, gentle mobilization of the duodenum may be needed.
在右侧LPN中，肝脏应在头侧的前位而暴露肾上极。在左侧LPN中，脾脏，结肠脾曲以及胰腺应使其倒向内侧。左侧的同侧结肠应被移开暴露肾门。在右侧可能需要适当移开十二指肠。
The ureter and gonadal vein packet are dissected en bloc and lifted antero-laterally off the psoas muscle towards the renal hilum. Extended dissection is used to precisely locate the renal vein and to visualize its entire anterior surface. We do not separately skeletonize the renal vein and artery during LPN. We think that individual vessel skeletonization is unnecessary, and might even be counter-productive for the following reasons:
1)it is not mandatory for achieving adequate clamping;
2) it might result in renal artery vasospasm;
3) it increases the risks of iatrogenic vascular injury with serious sequelae;
4) some hilar fat might cushion the renal vessels, minimizing crush injury to the endothelium by the clamp, especially in cases of atherosclerotic renal arteries;
5) it requires ≈ 30 min of precious operating time, detracting the surgeon from the primary goal of the procedure. The medial aspect of the upper pole kidney is mobilized away from the adrenal gland, and anteriorly off the psoas muscle. The en bloc renal hilum, including its anterior, posterior, inferior and superior aspects, and some intact hilar fat, are prepared. Abnormally thick fatty tissue in the hilar area is dissected to avoid incomplete Satinsky occlusion.
输尿管和性腺静脉于腰大肌的前外侧被整体提起朝向肾门切除。扩大性切除用于精确地定位肾静脉及其看清整个血管前壁表面。在LPN过程中不分离肾动静脉轮廓，因其并无必要，如分离可能由于以下原因达不到预期目的：1）不必充分夹紧；2）可能导致肾动脉痉挛；3）增加医源性血管损伤及其严重后遗症的风险；4）肾门脂肪可能对于肾脏血管起到缓冲作用，减少钳夹对于上皮组织的挤压伤，特别是对于动脉粥样硬化的肾脏动脉病例；5）导致达到手术目的的时间中（增加）花费大约30分钟宝贵手术时间。肾脏上极的内侧可通过肾上腺开始从腰大肌前方分离。整个肾门，包括其前方，后方，上下面以及一些肾门脂肪都要先处理。在肾门区域异常厚的脂肪组织需切开避免Satinsky缝合不全。
Through the dedicated suprapubic port in the lower abdomen, a Satinsky vascular clamp can now be inserted parallel to the aorta and inferior vena cava and test-deployed to confirm complete clamping of the en bloc renal hilum with safety and confidence. Any secondary renal arteries or veins must be identified carefully, and clamped individually if necessary, with bulldog clamps.
MOBILIZATION OF THE KIDNEY 肾脏的松解
Gerota's fascia is entered, and the kidney defatted and mobilized enough to expose the tumour and surrounding normal renal parenchyma. Fat removal from most of the renal surface
1) increases kidney mobility;
2) enhances visualization of any secondary satellite tumours,;
3) allows multidirectional intraoperative ultrasonography (US);
4) increases versatility for tumour resection and suturing angles. Adequate staging of potential T3a tumours and safe tumour mobilization during resection are achieved by maintaining intact the perirenal fat overlying the tumour.
进入Gerota筋膜后，分离肾脏脂肪并充分暴露肿瘤以及正常肾实质周围。从肾脏表面去除大部分脂肪：1）增加肾脏移动度；2）看清续发的卫星肿瘤；3）可在术中进行多方向超声检查（US）；4）可在多面切除肿瘤并在各个角度缝合。如为T3 期肿瘤可连同肿瘤表面的肾周脂肪囊一起切除。
Massimiliano Spaliviero and Inderbir S. Gill
Section of Laparoscopic and Robotic Surgery, Glickman Urological Institute,
The Cleveland Clinic Foundation, Cleveland, OH, USA
缩略语：open partial nephrectomy （OPN），laparoscopic PN （LPN）
For transperitoneal LPN, the patient is placed in a 45–60°lateral position on the operating table.
经腹腹腔镜肾部分切除术，患者于术台上摆45-60度侧卧位。
To prevent postoperative neuromuscular strain, the head, neck, arms, axilla, hips, legs and ankles are each ergonomically placed in a neutral position and generously padded with foam padding. Care is taken not to obstruct any i.v. line. The patient is secured to the operating table at the level of chest and iliac crest, using 15 cm silk tape, thus permitting safe table rotation during LPN.
为预防术后神经肌肉紧张，头部，颈部，手臂，腋区，臀部，腿部以及踝关节都应置于一种适中位置并用泡沫垫起。（体位上的）护理不应阻碍静脉通道。患者应确保在胸部至髂骨之间的水平术台上，用15cm带子固定，在腹腔镜肾部分切除术中能安全旋转。
To obtain pneumoperitoneum, a Veress needle is placed into the ipsilateral lower abdominal quadrant along the midclavicular line. CO2 pneumoperitoneum (15 mmHg) is achieved and four secondary ports are placed: a 12-mm laparoscopic port (primary port) placed lateral to the rectus muscle at the level of the umbilicus; a subcostal port lateral to the rectus muscle at the 12th rib costochondral margin (on the right side; this subcostal 10/ 12 mm port allows passage of suture needles for the right-handed surgeon; on the left side, this subcostal port is typically a 5-mm port); a 10/12 mm port for the laparoscopic camera is placed 3 cm inferior and medial to the subcostal port; a 5-mm port is inserted at the mid-axillary line near the tip of the 11th rib, and used to place lateral counter-traction during renal hilar dissection, and to grasp renorraphy sutures during renal parenchymal repair; and finally, a 10/12-mm port is placed in the suprapubic area at the lateral edge of the rectus muscle for insertion of the Satinsky vascular clamp. This standard configuration can be varied according to the individual patient anatomy and tumour location.
气腹建立：沿锁骨中线置入Veress针进同侧下腹，建立气腹通入二氧化碳达15mmHg；置入4个辅助通道：12mm腹腔镜通道（主通道）位于脐水平腹直肌的外侧缘进入；侧通道位于腹直肌线的第12肋缘（在右侧，此肋骨下10/ 12mm通道可允许右手外科医师的使用缝合针通过；在左侧，肋骨下的通道一般为5mm）；在肋骨内侧以下3公分设置一10/12 mm通道置入腹腔镜摄像（系统），在近11肋的腋中线设置5mm通道以便置入（器械）在肾门切除时对抗牵拉以及在肾实质修补时抓持renorraphy缝合。最后在耻骨弓上区域的腹直肌外侧缘设置10/12-mm通道以置入Satinsky血管夹。标准的通道设置依赖于病人个体解剖及肿瘤定位。
During right LPN, the liver is retracted anteriorly and cephalad to expose the renal upper pole. During left LPN, the spleen, splenic flexure and pancreas are reflected medially. On either side, the ipsilateral colon is mobilized to expose the renal hilum. On the right side, gentle mobilization of the duodenum may be needed.
在右侧LPN中，肝脏应在头侧的前位而暴露肾上极。在左侧LPN中，脾脏，结肠脾曲以及胰腺应使其倒向内侧。左侧的同侧结肠应被移开暴露肾门。在右侧可能需要适当移开十二指肠。
The ureter and gonadal vein packet are dissected en bloc and lifted antero-laterally off the psoas muscle towards the renal hilum. Extended dissection is used to precisely locate the renal vein and to visualize its entire anterior surface. We do not separately skeletonize the renal vein and artery during LPN. We think that individual vessel skeletonization is unnecessary, and might even be counter-productive for the following reasons:
1)it is not mandatory for achieving adequate clamping;
2) it might result in renal artery vasospasm;
3) it increases the risks of iatrogenic vascular injury with serious sequelae;
4) some hilar fat might cushion the renal vessels, minimizing crush injury to the endothelium by the clamp, especially in cases of atherosclerotic renal arteries;
5) it requires ≈ 30 min of precious operating time, detracting the surgeon from the primary goal of the procedure. The medial aspect of the upper pole kidney is mobilized away from the adrenal gland, and anteriorly off the psoas muscle. The en bloc renal hilum, including its anterior, posterior, inferior and superior aspects, and some intact hilar fat, are prepared. Abnormally thick fatty tissue in the hilar area is dissected to avoid incomplete Satinsky occlusion.
输尿管和性腺静脉于腰大肌的前外侧被整体提起朝向肾门切除。扩大性切除用于精确地定位肾静脉及其看清整个血管前壁表面。在LPN过程中不分离肾动静脉轮廓，因其并无必要，如分离可能由于以下原因达不到预期目的：1）不必充分夹紧；2）可能导致肾动脉痉挛；3）增加医源性血管损伤及其严重后遗症的风险；4）肾门脂肪可能对于肾脏血管起到缓冲作用，减少钳夹对于上皮组织的挤压伤，特别是对于动脉粥样硬化的肾脏动脉病例；5）导致达到手术目的的时间中（增加）花费大约30分钟宝贵手术时间。肾脏上极的内侧可通过肾上腺开始从腰大肌前方分离。整个肾门，包括其前方，后方，上下面以及一些肾门脂肪都要先处理。在肾门区域异常厚的脂肪组织需切开避免Satinsky缝合不全。
Through the dedicated suprapubic port in the lower abdomen, a Satinsky vascular clamp can now be inserted parallel to the aorta and inferior vena cava and test-deployed to confirm complete clamping of the en bloc renal hilum with safety and confidence. Any secondary renal arteries or veins must be identified carefully, and clamped individually if necessary, with bulldog clamps.
MOBILIZATION OF THE KIDNEY 肾脏的松解
Gerota's fascia is entered, and the kidney defatted and mobilized enough to expose the tumour and surrounding normal renal parenchyma. Fat removal from most of the renal surface
1) increases kidney mobility;
2) enhances visualization of any secondary satellite tumours,;
3) allows multidirectional intraoperative ultrasonography (US);
4) increases versatility for tumour resection and suturing angles. Adequate staging of potential T3a tumours and safe tumour mobilization during resection are achieved by maintaining intact the perirenal fat overlying the tumour.
进入Gerota筋膜后，分离肾脏脂肪并充分暴露肿瘤以及正常肾实质周围。从肾脏表面去除大部分脂肪：1）增加肾脏移动度；2）看清续发的卫星肿瘤；3）可在术中进行多方向超声检查（US）；4）可在多面切除肿瘤并在各个角度缝合。如为T3 期肿瘤可连同肿瘤表面的肾周脂肪囊一起切除。
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