Zheng Bobo, Wang Nan, Wu Tao, Qiao Qing, Gong Li, Zhou Shuai, Zhang Bo, Yang Ying, Wang Ke, Zhai Yulong, He Xianli
Department of General Surgery, Tangdu Hospital, Air Force Medical University, Xi'an 710038, China.
Department of Pathology, Tangdu Hospital, Air Force Medical University, Xi'an 710038, China.
Zhonghua Wei Chang Wai Ke Za Zhi. 2018 Jun 25;21(6):673-677.
To investigate the application value of the clearance of No.253 lymph nodes with priority to fascial space and preserving left colic artery (LCA) in patients undergoing laparoscopic radical proctectomy.
From August 2015 to August 2016, 97 consecutive middle-low rectal cancer patients underwent laparoscopic radical proctectomy using the clearance of No.253 lymph nodes with priority to fascial space and preserving LCA at Department of General Surgery, Tangdu Hospital. Among 97 patients, 45 were females , 52 were males, mean age was (64.3±5.5) years and mean BMI was (22.4±1.8) kg/m. Brief steps of this clearance: traditional medial approach was the commencement of the dissection at the membrane bridge line in front of iliac vascular bifurcation, then entering into the Toldt's space; superior rectal artery served as the top of the tent and the Toldt's space was extended as far as possible; blunt separation was developed caudally (reaching 2 cm below the sacral promontory), cephalad (reaching the lower part of the pancreas), left laterally (reaching Toldt's line), dextrally (reaching abdominal aorta); after giving priority to fascias space, from the root of inferior mesenteric artery, LCA was exposed and No.253 lymph nodes were dissected. This regimen was suitable for the rectal adenocarcinoma patients without distant metastasis.
There was no tension in the intestine and mesenteria after anastomosis in all the 97 patients. One patient received LCA ligation during the clearance, because of thinner LCA resulting in bleeding. The other 96 cases completed the clearance and operation successfully. The mean No.253 lymphadenectomy time was 11-27(17.1±5.3) minutes. The mean number of harvested No.253 lymph node was 0-6(4±2). The No.253 lymph nodes of 6 patients were positive. No.253 regional mesentery was complete in 95 patients. The total harvested number of lymph node was 11-26(17.3±5.3). Six patients with positive lymph nodes aged from 68 to 72 years old and all of them underwent TME operation 6-8 weeks after neoadjuvant chemoradiotherapy. The mean operative time was 89-189(125±35) minutes. The mean estimated blood loss was 10.5-38.6(22.4±10.5) ml. The first exhaust time was 3.0-6.0(5.6±2.1) days. The mean time to extracting the drainage tube was 3.0-5.0(4.5±2.5) days. Anastomotic fistula appeared in 1 case and hemorrhage appeared in 1 case, and these 2 cases were cured by conservative treatment. No perioperative death occurred. The mean postoperative hospital stay was 3.0-10.0(3.6±2.6) days.
The clearance of No.253 lymph nodes with priority to fascial space and preserving LCA in laparoscopic radical proctectomy is safe and feasible.
探讨在腹腔镜直肠癌根治术中优先处理筋膜间隙并保留左结肠动脉（LCA）清扫第253组淋巴结的应用价值。
2015年8月至2016年8月，唐都医院普通外科对97例中低位直肠癌患者行腹腔镜直肠癌根治术，采用优先处理筋膜间隙并保留LCA清扫第253组淋巴结。97例患者中，女性45例，男性52例，平均年龄（64.3±5.5）岁，平均体质指数（BMI）为（22.4±1.8）kg/m²。该清扫术的简要步骤：采用传统内侧入路，从髂血管分叉前方的膜桥线开始解剖，进入Toldt间隙；以直肠上动脉为帐篷顶，尽可能向远处扩展Toldt间隙；钝性分离向尾侧（达骶岬下2 cm）、头侧（达胰腺下部）、左侧（达Toldt线）、右侧（达腹主动脉）；优先处理筋膜间隙后，从肠系膜下动脉根部暴露LCA并清扫第253组淋巴结。该术式适用于无远处转移的直肠腺癌患者。
97例患者吻合后肠管及系膜均无张力。1例患者在清扫过程中因LCA较细导致出血而结扎LCA。其余96例均成功完成清扫及手术。第253组淋巴结平均清扫时间为11 - 27（17.1±5.3）分钟。第253组淋巴结平均收获数量为0 - 6（4±2）枚。6例患者第253组淋巴结阳性。95例患者第253组区域系膜完整。淋巴结总收获数量为11 - 26（17.3±5.3）枚。6例淋巴结阳性患者年龄为68～72岁，均在新辅助放化疗后6～8周行TME手术。平均手术时间为89 - 189（125±35）分钟。平均估计失血量为10.5 - 38.6（22.4±10.5）ml。首次排气时间为3.0 - 6.0（5.6±2.1）天。引流管拔除平均时间为3.0 - 5.0（4.5±2.5）天。出现吻合口瘘1例，出血1例，均经保守治疗治愈。无围手术期死亡。术后平均住院时间为3.0 - 10.0（3.6±2.6）天。
在腹腔镜直肠癌根治术中优先处理筋膜间隙并保留LCA清扫第253组淋巴结是安全可行的。
