Laparoscopic Extralevator Abdominoperineal Excision: Experience from a Single Center
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摘要:
目的 探索腹腔镜下完成经肛提肌外腹会阴联合直肠癌切除(extralevator abdominoperineal excision, ELAPE)手术的可行性。 方法 回顾性分析本院2012年6月至2013年8月实施的12例腹腔镜下ELAPE手术的围手术期特点, 手术过程中侧方完全切除肛提肌组, 后方切除其在尾骨的附着点, 前方根据肿瘤分期和位置决定是否行周围脏器的扩大切除。术中不更换体位, 会阴切口缝合皮下和皮肤, 缝闭盆底腹膜。从手术时间、术中出血、淋巴结获取数目、术后并发症等方面判断手术的可行性。 结果 患者平均年龄(65.2±12.5)岁, 体重指数21.6±3.1;肿瘤下缘距肛缘(3.3±0.7)cm; 手术时间(176.1±27.5)min, 术中出血(49.6±38.2)ml; 淋巴结获取数目(18.3±7.8)枚, 所有肠管断端及侧切缘均阴性; 2例发生尿潴留, 9例患者会阴切口达到甲级愈合。 结论 据手术短期效果, 术中不更换体位, 根据个体情况选择性行周围脏器的扩大切除, 在腹腔镜下完成ELAPE手术是可行的。 Abstract:Objective To investigate the feasibility of extralevator abdominoperineal excision (ELAPE) under laparoscope. Methods We retrospectively analyzed 12 patients with distal rectal cancer who underwent ELAPE in our center from June 2012 to August 2013. During the procedures, the levator ani muscles were cut off laparoscopically at its origin at both sides on the pelvic wall, and its attachment on coccyx was removed posteriorly. The dissection plane was taken along the Denonvillier fascia anteriorly as far as possible to the perineal body. The adjacent organs were removed if invaded by the tumors. The anus and its surrounding tissue were removed by perineal approach without changing patients' positions. The pelvic perinium was closed laparoscopically to prevent the intestine dropping. The operation time, blood loss, retrieval of lymph nodes, radial margin, and postoperative complications were recorded. Results The patients aged (65.2±12.5)years and their body mass index was 21.6±3.1. The distance from lower edge of tumor to anal verge was (3.3±0.7)cm. The procedure lasted (176.1±27.5) minutes, with a blood loss of (49.6±38.2)ml. The average number of node retrieval was 18.3±7.8, and no positive radial margin was identified. The postoperative complications included urinary retention in 2 patients. The perineal incision appeared to be class A healing in 9 patients. Conclusion By extensively removing the levator ani muscles laterally and posteriorly, ELAPE procedure can be accomplished under laparoscope without changing operative position or flap repair of the pelvic floor. -
Key words:
- rectal cancer, operation /
- laparoscope /
- levator ani muscle
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图 3 传统APR手术切除标本的背面观(A)和正面观(B),红色虚线显示手术切除平面所致的狭窄“腰身”
APR:同图 2
图 4 ELAPE手术切除标本的背面观(A)和正面观(B),在不同高度断离肛提肌不形成狭窄“腰身”,红色虚线显示手术切除标本呈现“柱状”
ELAPE:同图 2
表 1 12例ELAPE手术患者的临床观察指标
病
例性
别年龄
(岁)BMI 新辅助治疗
前超声/MRI
分期新辅助治疗 ASA
评分手术
时间
(min)术中
出血量
(ml)距肛缘
距离
(cm)肿瘤位置 扩大切除
范围术后并发症/
伤口愈合淋巴结
获取
数目侧
切
缘术后
TNM
分期1 男 72 19.27 T3N1/(-) 无(患者拒绝) 2 230 50 4 前壁1/2周 常规 无/甲级愈合 20 (-) T2N0 2 男 71 19.60 T3N0/(-) 放疗,卡培他滨 2 175 100 4 环周生长 常规 无/甲级愈合 25 (-) T2N0 3 女 83 22.72 (-)/T3N0 无(患者拒绝) 2 215 20 5 左后1/4周 常规 无/乙级愈合 17 (-) T3N1 4 女 81 25.39 (-)/T2N1 无(患者拒绝) 1 145 20 3 前壁2/3周 常规 尿潴留/甲级愈合 14 (-) T3N0 5 女 42 26.56 T2N0/T2N0 无 2 145 120 3 前左侧1/4周 切除部分
阴道后壁无/甲级愈合 11 (-) T3N0 6 女 60 23.74 T2N0/T3N0 无(患者拒绝) 1 144 60 3 右侧1/2周 常规 无/丙级愈合 15 (-) T2N0 7 男 68 17.65 T3N1/T3N1 无(患者拒绝) 1 185 100 3 前壁2/3周 切除部分
前列腺无/乙级愈合 13 (-) T3N0 8* 女 58 24.80 T1N0/(-) 无 2 160 50 3 后右侧1/3周 常规 无/甲级愈合 21 (-) T3N1 9 女 75 18.83 T2N0/(-) 无 2 166 30 3 右侧1/4周 常规 无/甲级愈合 18 (-) T1N0 10 男 54 23.14 T3N0/(-) 无(患者拒绝) 1 168 20 3 后壁2/3周 切除尾骨 尿潴留/甲级愈合 16 (-) T2N0 11 女 68 17.63 T3N1/(-) 放疗, XELOX 2 185 20 3 右侧1/2周 切除尾骨 无/甲级愈合 10 (-) T3N1 12 女 50 20.31 T2N0/T2N0 无 1 195 5 3 前右侧1/4周 切除尾骨 无/甲级愈合 39 (-) T2N0 ELAPE:经肛提肌外腹会阴联合直肠癌切除术;BMI:体重指数;MRI:磁共振成像;ASA:美国麻醉医师学会;XELOX:奥沙利铂联合卡培他滨;
* 该患者 直肠指检发现溃疡较深,肿瘤固定,因此选择ELAPE手术 -
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