两种成型方法在腹腔镜肾部分切除术治疗复杂性肾肿瘤中的应用

发布时间：2018-08-01 09:00

【摘要】：腹腔镜肾部分切除术是治疗肾肿瘤的有效方法.肾部分切除术从避免透析的绝对适应症（如孤立肾、双肾肿瘤或遗传综合症）逐渐发展到小于7cm的肾肿瘤，，甚至对侧肾正常的患者，肾部分切除术的益处包括可以降低慢性肾损害及减少心血管病发生率，同时具有与肾癌根治相当的病理结果。多种改进方法试图缩短肾热缺血时间，如：使用Hem-o-lok夹、早期开放及零缺血技术。降低热缺血时间最大的影响包括正确的持针、正确的将针放置在肾皮质上、将缺损的肾组织靠拢及有效的缝合。术者的经验可以缩短手术时间及成型缝合时间，但是，有时即使经验丰富的术者要保持30分钟的热缺血时间也是非常困难的，尤其对于复杂的肾肿瘤。本课题拟从术后并发症和成型费用研究两个方面来探讨缝合方式对腹腔镜肾部分切除术治疗复杂性肾肿瘤患者的影响。第一部分：两种成型方法在腹腔镜肾部分切除术治疗复杂性肾肿瘤中的应用目的通过比较倒刺缝合与传统缝合在腹腔镜下肾部分切除术治疗复杂性肾肿瘤中热缺血时间及并发症，研究倒刺缝合的安全性和有效性。方法2009年3月至2012年3月采用腹腔镜下肾部分切除术治疗的复杂性肾肿瘤（R.E.N.A.L评分≥7）患者78例，术中均采用分层连续缝合。根据肾脏缝合方法分为倒刺组和传统组。倒刺组30例，男18例，女12例。平均年龄48岁。取2-0倒刺线1根，自线中间剪成2根。先于线尾固定1枚Hem-o-lok夹，用于缝合肿瘤床内层,1-0倒刺线缝合外层;传统组48例，男36例，女12例。取15cm2-0单乔线,内层缝合方法同倒刺组，外层采用20cm1-0微乔线，连续缝合肾缺损，每针出肾包膜后均夹1枚Hem-o-lok夹。比较两组患者手术时间、围手术期结果、围手术期并发症等。结果传统组与倒刺组手术时间分别为79、73min，术中估计平均出血量分别为120、102ml,两组间比较差异均无统计学意义（P＞0.05）。传统组中1例术中开放血管后出血较多，遂中转开放手术；5例术后输血；1例术后出现尿漏，给予留置双J管；1例于术后16d出现延迟出血，行选择性肾血管栓塞治疗,1例术后出现切口疝，行修补治疗。倒刺组无术中并发症,1例术后2d出血，予输血。1例出现尿漏，予留置双J管治疗，1例术后出现淋巴漏，经改变饮食保守治疗后治愈；两组术后30d内血清肌酐比较差异无统计学意义（P＞0.05），无需二次入院治疗的患者。出血后需干预的病例传统组（7/48,14.5%）为倒刺组（1/30,3.3%）的4.3倍，但两组比较差异无统计学意义（P＞0.05）。平均肾热缺血时间传统组为24.8min，倒刺组为18min，两组比较差异有统计学意义（P＜0.05）。结论倒刺缝合在腹腔镜下肾部分切除术治疗复杂性肾肿瘤中，可以缩短平均热缺血时间,可能减少围手术期出血率。第二部分：倒刺缝合线在腹腔镜肾部分切除术治疗复杂性肾肿瘤中的应用目的通过比较倒刺缝合与传统缝合在腹腔镜下肾部分切除术治疗复杂性肾肿瘤中热缺血时间及并发症，研究倒刺缝合的安全性和有效性。回顾分析64例复杂性肾肿瘤（RENAL Score≥7）行腹腔镜肾部分切除术（LPN）的患者资料。术中均采用分层连续缝合，倒刺缝合组（Quill SRS）34例，传统缝合组（non-SRS）30例。两组病例采用RENAL Score评分系统进行匹配。比较两组患者临床特点、围手术期结果、围手术期并发症及缝合费用。所有手术均由同一术者完成。结果：平均热缺血时间（WIT）在倒刺缝合组明显短于传统缝合组（18vs24.8minp=0.021），缝合费用在倒刺缝合组明显少于传统缝合组（1708vs2070元，p=0.035）。两组围手术期肾功能和并发症无明显差异。结论：倒刺缝合线在腹腔镜肾部分切除术治疗复杂性肾肿瘤肾成型中是安全、有效的。可以缩短平均热缺血时间（WIT）并降低缝合费用。
[Abstract]:Partial nephrectomy is an effective treatment for renal tumors. Partial nephrectomy from absolute indications of avoiding dialysis (such as solitary kidney, double kidney tumor or hereditary syndrome) gradually develops to less than 7cm of kidney tumors, and even to patients with normal kidney, the benefits of partial nephrectomy include reducing chronic renal damage and reducing the heart. The incidence of angiopathy has the same pathological results as radical nephrectomy. A variety of improved methods try to shorten the time of renal ischemia, such as using the Hem-o-lok clip, early opening and zero ischemia. The greatest effects of reducing the time of thermal ischemia include the correct needle holding, the correct placement of the needle on the renal cortex, and the closure of the defective renal tissue. Effective suture. The experience of the operator can shorten the time of operation and the time of forming suture. However, it is sometimes difficult to maintain 30 minutes of hot ischemic time, especially for complicated renal tumors, especially for complicated renal tumors. This subject is to explore the suture way to the abdominal cavity from two aspects of postoperative complications and molding costs. The effect of partial nephrectomy for the treatment of complicated renal tumors. Part 1: the application of two molding methods in the treatment of complex renal tumors by laparoscopic partial nephrectomy Methods from March 2009 to March 2012, 78 cases of complicated renal tumor (R.E.N.A.L score > 7) were treated with laparoscopic partial nephrectomy, and 78 cases were treated with stratified continuous suture. According to the method of suture, 30 cases, 18 men and 12 women. The average age was 48. Age 1, 2-0 sowing thread, cut into 2 roots from the middle of the line. 1 Hem-o-lok clips were fixed at the end of the line at the end of the line. It was used to suture the inner layer of the tumor bed and to suture the outer layer by the 1-0 barbed line; the traditional group 48 cases, male 36 cases and 12 women. The inner suture method was the same as the reverse stink group, the outer layer was used 20cm1-0 micro Joe line to suture the kidney defect continuously, and each needle after the renal capsule was pinched 1. Hem-o-lok clip. Compared the operation time of the two groups of patients, perioperative results and perioperative complications. Results the operation time of the traditional group and the barn group was 79,73min, and the average amount of bleeding was 120102ml respectively during the operation. There was no significant difference between the two groups (P > 0.05). Then, 5 cases were transferred to open operation, 5 cases of postoperative blood transfusion, 1 cases of postoperative urinary leakage and double J tube, 1 cases of delayed hemorrhage after operation, selective renal vascular embolization, 1 cases of postoperative incisional hernia, repair treatment. There were no intraoperative complications, 1 cases of postoperative 2D bleeding, and.1 cases of blood transfusion in.1 cases, the double J tube treatment was retained, 1 In the two groups, there was no significant difference in serum creatinine in the two groups (P > 0.05), and there was no need for two times of hospitalization. The traditional group (7/48,14.5%) after bleeding was 4.3 times as high as that of the barn group (1/30,3.3%), but there was no significant difference between the two groups (P > 0.05). The average time of renal ischemia was 24.8min in the traditional group and 18min in the barn group. The difference between the two groups was statistically significant (P < 0.05). Conclusion the mean thermal ischemia time can be shortened in the treatment of complicated renal tumor by the suture of the reverse needle suture in the laparoscopic nephrectomy, and the rate of bleeding in the perioperative period may be reduced.
The second part: application of barbed suture in laparoscopic partial nephrectomy for complex renal tumors.
Objective to compare the thermal ischemia time and complications in the treatment of complicated renal tumors by comparing the traditional suture and the traditional suture in the treatment of complicated renal tumor. The safety and effectiveness of the suture were studied. The data of 64 cases of complicated renal tumor (RENAL Score > 7) underwent laparoscopic partial nephrectomy (LPN). Continuous suture, 34 cases of Quill SRS and 30 cases in the traditional suture group (non-SRS). The two cases were matched by RENAL Score scoring system. The clinical characteristics, perioperative results, perioperative complications and suture cost were compared in the two groups. All the operations were performed by the same operator. Results: the average thermal ischemia time (WIT) was reversed. The needling suture group was significantly shorter than the traditional suture group (18vs24.8minp=0.021), and the suture cost in the spiny suture group was significantly less than the traditional suture group (1708vs2070 yuan, p=0.035). There was no significant difference in the renal function and complications during the perioperative period of the two groups. Conclusion: the spiny suture is safe in the treatment of complicated renal tumor by laparoscopic partial nephrectomy. It can shorten the mean warm ischemia time (WIT) and reduce the cost of suture.
【学位授予单位】：中国人民解放军医学院
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R737.11

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