保留盆腔自主神经腹腔镜经肛拖出直肠癌根治术.docVIP

保留盆腔自主神经腹腔镜经肛拖出直肠癌根治术[摘要] 目的：分析男性患者采用保留盆腔自主神经的腹腔镜经肛拖出直肠癌根治术后患者的预后和性功能变化情况，评价该手术安全性和可行性。方法：选择本院就诊的中低位直肠癌患者分为腹腔镜组和开腹组，分别进行保留盆腔自主神经的腹腔镜经肛拖出直肠癌根治术和开腹直肠癌根治术。以问卷形式调查患者的排尿及性功能情况。结果：开腹组术后性能力障碍者9例（30.0%），腹腔镜组术后性能力障碍者3例（8.3%），差异有统计学意义（P0.05）。结论：腹腔镜经肛拖出直肠癌根治术较开腹直肠癌根治术能更好地保护盆腔自主神经，保留患者的性功能，具有可靠的安全性和可行性, 并由于其更微创，易于被患者接受，值得在临床应用。 [关键词] 腹腔镜；直肠癌；全系膜直肠切除术；神经保护 [中图分类号] R735.3+7[文献标识码] C [文章编号] 1674-4721（2011）06（b）-018-03 Laparoscopic transanal pull-through with nerve sparing radical resection of rectal carcinoma YUAN Long, LI Zhi, XU Benling, WU Huize, HAN Guangsen Department of General Surgery, Zhengzhou University Affiliated Tumor Hospital (Henan Tumor Hospital), Henan Province, Zhengzhou 450008, China [Abstract] Objective: To explore the efficacy, feasibility, safety of laparoscopic transanal pull-through (LTPT) with nerve sparing radical resection of rectal carcinoma. Methods: Bladder and male sexual function were studied by means of a questionnaire on the basis of the international prostatic symptom score (IPSS) and international index of erectile function (IIEF). In addition, bladder function was determined by means of postvoid residual urine measurement. Outcomes were compared between patients who underwent open (n=30) and laparoscopic (n=36) transanal pull-through with nerve sparing radical resection of rectal carcinoma. Results: Impotency after surgery was experienced by 9 of 30 preoperatively sexually active males (30.0%) in open group and 3 of 36 males (8.3%) in laparoscopic group (P=0.04). It had significant difference in EF domain score between open group and laparoscopic group after surgery 3 months and 6 months (P 1.2 保留神经的条件 ①癌肿未侵犯直肠固有筋膜；②直肠旁淋巴结无明显转移；③肿瘤直径小于 3 cm，肿瘤侵犯直肠周径1/3以下；④病理类型为高中分化腺癌；⑤年龄小于 60 岁。 1.3 手术方法 两组均行保留全部或部分盆腔自主神经，重点是手术操作过程中解剖出神经并加以保护。开腹组直肠肠管及系膜切除须严格遵循TME原则，在直视下锐性解剖，完整切除包裹在盆脏筋膜内的直肠及其系膜，对低位癌肿保证切缘位于原发灶远端3 cm以下。开腹组淋巴结清扫依据董新舒等[4]报道的程序：先从肠系膜下动脉根部上1~2 cm处开始向下清除脂肪及淋巴组织，至腹主动脉的前面，游离、并以吊带牵起上腹下神经，自上而下清除腹主动脉及下腔静脉周围的结缔组织。至左、右髂总动脉