1、肠系膜下动脉优先解剖联合完全内侧入路结肠脾曲游离技术在腹腔镜左半结肠癌根治术中的应用研究*胡刚1，刘军广2，邱文龙1，梅世文1，李博1，汤坚强11国家癌症中心国家肿瘤临床医学研究中心中国医学科学院北京协和医学院肿瘤医院结直肠外科北京1000212北京大学第一医院肝胆胰外科北京100034摘要 目的探讨“肠系膜下动脉优先解剖联合完全内侧入路”（priority anatomy of the inferior mesenteric artery combinedwith complete medial approach，IMACMA）结肠脾曲游离技术在腹腔镜左半结肠癌根治术中的应用效果。方法收集2
2、016年7月至2021年12月由本团队实施腹腔镜左半结肠癌根治术的74例患者的临床资料进行回顾性分析，按照手术方式的不同，将患者分为传统入路（traditional approach，TA）组与IMACMA组，每组纳入患者例数分别为43例、31例。将两组患者的临床基线资料按照11的比例进行倾向性评分匹配（propensity score matching，PSM），最终每组各纳入22例患者进行分析。记录两组术中情况（手术时间，术中出血量，脾出血事件，淋巴结清扫总数，253组淋巴结清扫数目）和术后恢复情况（术后住院时间，Clavien-Dindo 级及以上的术后并发症发生情况）。结果与TA组相比
3、，IMACMA组的平均手术时间更短，中位术中出血量更少，253组淋巴结清扫数目更多，差异均有统计学意义（均P0.05）。TA组共发生Clavien-Dindo级及以上的术后并发症2例，均为肠梗阻；IMACMA组共发生Clavien-Dindo级及以上的术后并发症3例，包括肠梗阻1例、腹腔感染1例、肺栓塞1例。两组Clavien-Dindo级及以上的术后并发症发生率及术后肠梗阻、腹腔感染、肺栓塞的发生率比较差异均无统计学意义（均P0.05）。两组均无术后腹腔出血病例。结论“肠系膜下动脉优先解剖联合完全内侧入路”结肠脾曲游离技术安全可行，有助于缩短手术时间和减少术中出血量，有利于253组淋巴结充分
4、清扫，且不增加围手术期并发症的发生率。关键词左半结肠癌；腹腔镜结肠癌根治术；肠系膜下动脉优先解剖；完全内侧入路；脾曲游离DOI:10.19668/ki.issn1674-0491.2023.03.011中图分类号:R735.3文献标志码:AApplication of priority anatomy of the inferior mesenteric artery combined withcomplete medial approach for splenic flexure mobilization in laparoscopic left-sided colon cancer rad
5、ical resection*Hu Gang1,Liu Junguang2,Qiu Wenlong1,Mei Shiwen1,Li Bo1,Tang Jianqiang11 Department of Colorectal Surgery,National Cancer Center,National Clinical Research Center for Cancer,Cancer Hospital,Chinese Academy of Medical Sciences and Peking Union Medical College,Beijing 100021,China;2 Depa
6、rtment of Hepatopancreatobiliary Surgery,Peking University First Hospital,Beijing 100034,ChinaAbstract ObjectivesTo explore the application effect of the technique of“priority anatomy of the inferior mesenteric arterycombined with complete medial approach(IMA-CMA)”for splenic flexure mobilization in
7、 laparoscopic left-sided colon cancer radical resection.MethodsWe retrospectively analyzed the clinical data of 74 patients who underwent laparoscopic left-sided colon cancer radical resection by our team from July 2016 to December 2021.The patients were divided into two groups based ondifferent sur
8、gical techniques:the traditional approach(TA)group(43 cases)and the IMA-CMA group(31 cases).The clinical baseline data of the two groups were propensity score matched in a 1:1 ratio,resulting in the inclusion of 22 patients in each groupfor analysis.Surgical parameters such as operation time,intraop
9、erative blood loss,spleen bleeding events,total number of lymphnodes yielded,and number of No.253 lymph nodes yielded were recorded and analyzed.Postoperative recovery measures such aslength of postoperative hospital stay and incidence of postoperative complications with Clavien-Dindo grade were als
10、o recordedand analyzed.ResultsCompared with the TA group,the IMA-CMA group showed a shorter mean operation time,a less median*中国医学科学院肿瘤医院“希望之星”人才项目；北京自然科学基金海淀前沿项目（L222054）；北京自然科学基金面上项目（4232058）共同第一作者通信作者，E-mail：doc_论著结直肠肛门外科 2023年6月 第29卷 第3期Journal of Colorectal&Anal Surgery Vol.29 No.3 Jun.2023260i
11、ntraoperative blood loss,and a higher number of No.253 lymph nodes yielded,all of which were statistically significant(P0.05).The TA group had 2 cases of postoperative complications with Clavien-Dindo grade,both of which were ileus,while the IMA-CMA group had 3 cases of postoperative complications w
12、ith Clavien-Dindo grade,including 1 case of ileus,1 case of intra-abdominal infection,and 1 case of pulmonary embolism.Therewere no statistically significant differences in the incidence of postoperative complications with Clavien-Dindo grade,as well asthe incidence of postoperative ileus,intro-abdo
13、minal infection,and pulmonary embolism between the two groups(P0.05).Therewere no cases of postoperative intra-abdominal bleeding in either group.ConclusionThe technique of IMA-CMA for splenic flexure mobilization is safe and feasible.It can shorten the operation time and reduce intraoperative blood
14、 loss,which is conducive toachieving a thorough No.253 lymph nodes yielded without increasing the incidence of perioperative complications.Keywords left-sided colon cancer,laparoscopic colon cancer radical resection,priority anatomy of the inferior mesenteric artery,complete medial approach,splenic
15、flexure mobilization目前，腹腔镜左半结肠癌根治术常用的传统手术入路方法包括中间入路法、外侧入路法、前方入路法，以及多数学者主张的“三路包抄”复合入路法。但是，前述传统入路方法容易受患者体型，助手反向操作不利，逆向的腹腔镜视角等因素的影响，学习曲线较长，尤其在左结肠动脉（left colicartery，LCA）根部的显露及肠系膜下动脉（inferiormesenteric artery，IMA）根部 D3清扫的关键环节中，常规头侧视角很难显露该区域，主刀常常受困于反向的视野，导致局部清扫效果不佳。本团队对腹腔镜左半结肠癌根治术的Trocar布局及手术步骤进行系列改良，包括
16、3 个关键技术：（1）“311”Trocar布局；（2）腹腔镜直肠手术视角下IMA优先解剖；（3）完 全 内 侧 入 路（completemedialapproach，CMA）结肠脾曲游离。由此，本团队将改良后的左半结肠癌根治术入路方法称为“肠系膜下动脉优先解剖联合完全内侧入路”（priority anatomyof the inferior mesenteric artery combined with complete medial approach，IMACMA）结肠脾曲游离技术（下文简称为“IMACMA”）。本研究将IMACMA 与传统入路（traditional approach，TA）的腹腔镜左半结肠癌根治术进行对比研究，从手术安全性、术中参数、术后并发症、淋巴结清扫效果等方面评估IMACMA的应用效果，从而为临床中相对少见的左半结肠肿瘤的手术路径优化提供新的、易于重复的手术操作流程参考。1资料与方法1 1.1 1研究对象研究对象回顾性收集2016年7月至2021年12月在中国医学科学院肿瘤医院及北京大学第一医院同一治疗组接受腹腔镜左半结肠癌根治术的患者的临床资料。纳入标准