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1、经脐单孔腹腔镜在上尿路及肾上腺手术中的应用（附 130 例报告）陈靖，权昌益，牛远杰*天津医科大学第二医院泌尿外科，天津泌尿外科研究所，天津泌尿外科基础医学重点实验室。天津市河西区平江道23号，邮编300211。注：*为通讯作者 E-摘要：目的 总结自制多通道经脐单孔腹腔镜下上尿路及肾上腺手术的技巧并评估其安全可行性。方法 2010 年 3 月至 2011 年 11 月对 130 例患者行经脐单孔腹腔镜下手术，其中肾囊肿去顶术 60 例，肾盂成形术 6 例，肾上腺切除术 2 例，输尿管切开取石术 40 例，肾部分切除术 10 例，无功能肾切除术 12 例。术中所用的自制通道由两个环和一个无菌手
2、套制而成。取脐正中约 2 cm 切口, 置入单孔多通道套件，将 10 mm, 10 mm, 5 mm, 3 个Trocar 放入其中, 以普通器械及可弯器械相配合，完成各项手术，切除物由脐部切口取出。结果 130 例手术均在腹腔镜下顺利完成，6 例因视野不清或操作困难，术中增加操作套管，无术中转开放。肾囊肿去顶术 60 例，平均手术时间(25.24.3)min，术中出血量平均(10.32.1)ml，术后平均住院时间(2.50.5)d。肾盂成形术 6 例，平均手术时间 (120.918.6)min，术中出血量平均(31.59.2)ml，术后平均住院时间(4.01.0)d。肾上腺手术 2 例，手术
3、时间分别为 50 和 60min，术中出血量分别为 50 和 51ml，术后住院时间分别为 3 和 4d。上段输尿管切开取石术 40 例，平均手术时间(60.09.5)min，术中出血量平均(32.19.4)ml，术后平均住院时间(4.01.0)d。肾部分切除术 10 例，平均手术时间 (134.515.2)min，肾脏热缺血时间(32.57.5)min，术中出血量平均(52.111.4)ml，术后平均住院时间(7.01.0)d。肾切除术 12 例，手术时间为(100.89.6)min，出血量为(125.725.4)ml，术后平均住院时间(5.01.0)d。术后随访月 216 个月，平均 9.
4、2 个月，未见不良并发症。结论 经脐单孔腹腔镜治疗上尿路及肾上腺病变安全可行，美容和微创治疗效果良好，但由于其难度较大在临床工作中需要谨慎推广。关键词：单孔腹腔镜; 经脐 ; 上尿路疾病。Single-port transumbilical laparoscopic Surgery in Upper Urinary Tract and Adrenalectomy with report of 130 CasesJing CHEN, Changyi QUAN,Yuanjie NIU *The secondary hospital of Tianjin medical University , T
5、ianjin Institute of Urology ,Tianjin Department of Urology of basic medical laboratory. Pingjiang Road 23, Hexi District, Tianjin300211 Abstract: Objective: To summarize the surgical techniques of single-port transumbilica laparoscopic surgery in upper urinary tract and adrenalectomy by using a self
6、 made port and evaluate its feasibility and safety. Methods: From March 2010 to November 2011, 130 patients were treated with single-port transumbilical laparoscopic surgery, which included 60 cases of renal cystectomy, 6 cases of pyeloplasty, 2 cases of adrenalectomy, 40 cases of ureteral incision,
7、 10 cases of partial nephrectomy, 12 cases of non-functioning kidney resection. The single-port was made up of two rings and a latex glove. A 2 cm incision was made in the middle of umbilicus, and the single-port was then inserted with three trocars (10,10, 5mm) inside. Tradition laparoscopic equipm
8、ent and flexible laparoscopic instruments were used to perform the procedures, and the removels were taken out from the port. Results: All laparoscopic operations were successfully completed without conversion to open surgery. The addition of ports was necessary in 6 cases as a result of difficult o
9、perations and unclear vision. 60 cases of renal cystectomy: mean operative time was (25.24.3) min, mean blood loss was (10.32.1)ml, mean postoperative hospital stay was (2.50.5)d. 6 cases of renal pelvis：mean operative time was (120.918.6)min, mean blood loss was (31.59.2)ml, mean postoperative hosp
10、ital stay was (4.01.0)d. 2 cases of adrenal operation: operative time was 50 and 60 min respectively, blood loss was 50 and 51 ml respectively, postoperative hospital stay was 3 and 4 d respectively. 40 cases of ureter incision to take stone: mean operative time was (60.09.5)min, mean blood loss was
11、 (32.19.4)ml, mean postoperative hospital stay was (4.01.0)d. 10 cases of partial nephrectomy operation: mean operative time was (134.515.2) min, (32.57.5) min of renal warm ischemia time, mean blood loss was (52.111.4)min, mean postoperative hospital stay was (7.01.0)d. 12 cases of renal resection
12、operation: mean operative time was (100.89.6)min, mean blood loss was (125.725.4)ml, mean postoperative hospital stay was (5.01.0)d. Postoperative follow-up for 2-33 months, mean 18.2 months, there were no adverse complications. Conclusions: The laparoscopic single-port transumbilical surgery for up
13、per urinary tract and adrenalectomy lesions is safe and feasible, and the cosmetic results are good, but it should be carefully widespread because of its difficulty in the clinical work.Key Words：Single-port laparoscopic surgery；transumbilical；Upper urinary tract diseases.2007 年，Raman 等 1报道第 1 例单孔腹腔
14、镜肾切除术以来, 泌尿外科单孔腹腔镜手术( laparoendoscopic single site surgery, LESS)的成功案例在国内外均已有报道 2, 但由于设备、器械、技术的限制, 目前尚未得到广泛应用。为探讨经脐单孔腹腔镜技术的安全性与可行性, 我科于 2009 年 3 月至 2011 年 11 月利用自制单孔通道完成了 130 例经脐单孔腹腔镜手术, 其中肾囊肿去顶术 60 例，肾盂成形术 6 例，肾上腺切除术 2 例，输尿管切开取石术 40例，肾部分切除术 10 例，无功能肾切除术 12 例。临床效果良好，现报道如下。对象与方法一、临床资料本组 130 例, 男 80 例
15、, 女 50 例。左侧 74 例, 右侧 56 例。平均年龄 54. 8 岁( 2877 岁) 。肾囊肿去顶术 60 例：其中单纯性肾囊肿 42 例，多发性 18 例。左侧 40 例，右侧 20 例。上极 38 例，下极 22 例。囊肿直径 52-102mm，平均 80.5mm。均主因腰部胀痛入院，8 例伴有血尿。术前经 B 超、 IV U 或腹部 CT 等检查确诊。肾盂成形术 6 例：男女各 3 例，年龄 23（18-47）岁，均有不同程度患侧腰部胀痛，病程 10-80d，有不同程度的肾积水。采用利尿肾图、 IVU、MRU 及肾盂输尿管造影等确诊。肾上腺切除术 2 例：分别为 48 岁和 6
16、4 岁女性，均查体发现左肾上腺占位病变，分别为：CT 示左侧肾上腺区 4.8*4.5cm 肿物，无强化，107.7363.04Hu；CT 示左肾上腺区含脂肿块，大小约 9.5*7.5*9.5cm，CT 值为 73HU。 （病理：均为髓质脂肪瘤） 。输尿管切开取石术 40 例：输尿管结石直径 1.52.2cm, 平均 1.8cm。术前经 B 超、 IV U 或腹部 CT 等检查确诊。病例选择标准: 体外冲击波碎石（ESWL）无效的质硬结石；不适合行输尿管镜的中、上段输尿管且伴有粘连的较大结石；无严重心肺功能不全, 无其他手术禁忌证。肾部分切除术 10 例：均因查体发现占位入院，男女各 5 例，年龄平均 32（25-45）岁，术前经 B 超、CT、MRI 等检查确诊。占位大小在 1.5cm1.5cm 至 3.2 cm3.4 cm 大小不等，均为单侧，其中左侧 6 例，右侧 4 例。肾小球滤过率、电解质及肝肾功能
