摘要
腹腔镜胃癌根治手术已广泛开展，适应证也逐渐从早期胃癌过渡到进展期胃癌。但由于胃的血供丰富、周围解剖较复杂，淋巴结清扫范围广，腹腔镜胃癌根治术难度较高。本文分享广东省人民医院普通外科胃肠专业组开展腹腔镜远端胃癌D2根治术的经验，包括Trocar位置的选择、手术入路及淋巴结清扫顺序等。Trocar的位置是手术视野质量保证的基础，建议观察孔选择在脐下约2 cm处，操作孔选择在双侧锁骨中线附近。合理的手术入路和淋巴结清扫顺序是腹腔镜远端胃癌D2根治术顺利进行的前提，也是胃周淋巴结清扫安全性和根治性的保证。我们团队采取主刀医师左侧站位、助手右侧站位、扶镜手在患者两腿之间的站位，这与＂从左到右＂、＂由近及远＂、＂由下而上＂的淋巴结清扫顺序相适应，有利于对幽门上下区域淋巴结的清扫，并可避免副损伤。在我们中心，淋巴结清扫顺序为首先清扫4sb组淋巴结并裸化胃大弯侧；变换体位，行幽门下区域淋巴结的清扫，切割闭合器切断十二指肠；再完成幽门上区域及胰腺上缘区域淋巴结的清扫，最后完成第1、3组淋巴结的清扫。不同中心的手术入路和淋巴结清扫顺序不尽相同，总的来说，腹腔镜远端胃癌D2根治术技术要求高，淋巴结根治性清扫难度大，要求术者熟悉胃周血管解剖及淋巴结引流特点，培养固定的团队，术中合理站位和变换患者体位，选择适合自己团队的手术入路和淋巴结清扫顺序，以使整个手术过程程序化、规范化、标准化，减少术中出血量，缩短手术时间。
Laparoscopic radical gastrectomy for gastric cancer has been widely applied in clinical practice, and its indications have been extended from early gastric cancer to advanced gastric cancer. It is acknowledged that laparoscopic radical gastrectomy is technically challenging because of the complexity of anatomy, rich blood supply, and extensive lymph node dissection. This paper primarily intends to share the experience of laparoscopic radical D2 gastrectomy for distal gastric cancer with details of choosing the location of Trocar, surgical approaches and the sequence of lymph node dissection. All the surgeries were performed at Department of General Surgery and Gastrointestinal Surgery, Guangdong General Hospital. The finding suggests that a correct laparoscopic Trocar placement is the foundation of adequate surgical field visualization. Under most circumstances, the observation hole should be around 2 cm below the umbilicus and the operating hole should be close to the bilateral clavicle midline. Furthermore, proper surgical approach and sequence of lymph node dissection are the prerequisites for successful laparoscopic radical D2 gastrectomy, as well as the reassurance of dissecting lymph node safely and comprehensively. The position of surgical team adopted in our center is that the surgeon stands to the left of the patient, with laparoscope operator stands in between patient′s legs while the first assistant positions himself opposite the surgeon on the right side of the patient. This position correlates to the rules of sequential lymph node dissection, which is＂from left to right＂,＂from proximal to distal＂and＂from inferior to superior＂. Therefore, it is conductive to inferior and superior pylorus region dissection and it can effectively prevent subsidiary-injury. In our center, the procedure of lymph node dissection has been standardized： the initial step is to undergo station 4sb dissection and greater gastric curvature clearance; then change the patient′s position to clean the sub-pyloric lymph node region and cut off the duodenum by linear stapler; followed by the clearance of inferior region of the pylorus and the upper margin of the pancreas; in the final step, the first and the third groups of lymph node dissection is performed. Although varied surgical approaches and sequences of lymph node dissection are applied in different hospitals, the techniques required for laparoscopic D2 radical gastrectomy for gastric cancer are sophisticated and advanced in general. Radical lymph node dissection is complicated, urging surgeons to familiarize themselves with the anatomy of gastric peripheral vascular system and characteristics of lymph node drainage. By designing and implementing effective strategies, such as formulating a regular team, positioning surgical team reasonably, changing a patient′s posture during operation, choosing an appropriate surgical approach and following a logically sequence of lymph node dissection, surgeons can standardize the complete surgical procedure, which ultimately reduces bleeding during surgery and shortens the operative time.
出处
《中华胃肠外科杂志》
CAS
CSCD
北大核心
2017年第8期857-861,共5页
Chinese Journal of Gastrointestinal Surgery
基金
卫生部医药卫生科技发展研究中心项目（W2013R65）
广东省自然科学基金（2016A030313762）
关键词
胃肿瘤
腹腔镜
根治术
规范化
Stomach neoplasms
Laparoscopy
Radical gastrectomy
Standardized
